Healthcare Provider Details

I. General information

NPI: 1285302737
Provider Name (Legal Business Name): SR MANSFIELD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 JEFFERSON ST
MANSFIELD LA
71052-2600
US

IV. Provider business mailing address

126 JEFFERSON ST
MANSFIELD LA
71052-2600
US

V. Phone/Fax

Practice location:
  • Phone: 318-872-1557
  • Fax:
Mailing address:
  • Phone: 318-872-1557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ABIGAIL HOWELL
Title or Position: PRACTICE MANAGER
Credential:
Phone: 318-294-2241