Healthcare Provider Details

I. General information

NPI: 1326466954
Provider Name (Legal Business Name): LOUISIANA COLLEGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 COLLEGE DR BOX 563
PINEVILLE LA
71359-1000
US

IV. Provider business mailing address

1140 COLLEGE DR
PINEVILLE LA
71359-3995
US

V. Phone/Fax

Practice location:
  • Phone: 318-487-7792
  • Fax: 318-487-7174
Mailing address:
  • Phone: 318-487-7792
  • Fax: 972-367-3451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL PATRICK BERRY
Title or Position: BILLING SERVICE MANAGER
Credential:
Phone: 314-598-1663