Healthcare Provider Details

I. General information

NPI: 1811209232
Provider Name (Legal Business Name): DESOTO HEALTHCARE CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 12/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

938 LOUISE ST
MANSFIELD LA
71052
US

IV. Provider business mailing address

PO BOX 1384
MANSFIELD LA
71052-1384
US

V. Phone/Fax

Practice location:
  • Phone: 318-871-1633
  • Fax: 318-871-1677
Mailing address:
  • Phone: 318-871-1633
  • Fax: 318-871-1677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD199935
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number1487481
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1996971
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number03124
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number020173
License Number StateLA

VIII. Authorized Official

Name: MS. CONNIE B GANNON
Title or Position: FAMILY NURSE PRACTITIONER
Credential: FNP
Phone: 318-871-1633