Healthcare Provider Details

I. General information

NPI: 1063701878
Provider Name (Legal Business Name): GPN MANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 HIGHLAND DR
MANY LA
71449-3718
US

IV. Provider business mailing address

PO BOX 3923
SHREVEPORT LA
71133-3923
US

V. Phone/Fax

Practice location:
  • Phone: 318-256-5691
  • Fax:
Mailing address:
  • Phone: 888-447-2450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateLA

VIII. Authorized Official

Name: MR. SAM D HUCKABEE
Title or Position: CEO
Credential:
Phone: 318-469-1132