Healthcare Provider Details

I. General information

NPI: 1417098385
Provider Name (Legal Business Name): LOUISIANA NEUROLOGIC SPECIALTIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7929 YOUREE DR
SHREVEPORT LA
71105-5538
US

IV. Provider business mailing address

7929 YOUREE DR
SHREVEPORT LA
71105-5538
US

V. Phone/Fax

Practice location:
  • Phone: 318-424-3268
  • Fax: 318-424-3280
Mailing address:
  • Phone: 318-424-3268
  • Fax: 318-424-3280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number09699R
License Number StateLA

VIII. Authorized Official

Name: DR. BENJAMIN BANG V. NGUYEN
Title or Position: OWNER
Credential: M.D.
Phone: 318-424-3268