Healthcare Provider Details

I. General information

NPI: 1295238327
Provider Name (Legal Business Name): B&C ARCHERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2018
Last Update Date: 03/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 EZELLE ST
RUSTON LA
71270-7218
US

IV. Provider business mailing address

PO BOX 2494
RUSTON LA
71273-2494
US

V. Phone/Fax

Practice location:
  • Phone: 318-251-3126
  • Fax:
Mailing address:
  • Phone: 318-255-3690
  • Fax: 318-251-6116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD206301
License Number StateLA

VIII. Authorized Official

Name: MR. RYAN C HARRISON
Title or Position: SOLE OWNER
Credential: MD
Phone: 512-658-0877