Healthcare Provider Details

I. General information

NPI: 1700138781
Provider Name (Legal Business Name): BREATHEAMERICA SHREVEPORT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 08/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463 ASHLEY RIDGE BLVD SUITE 100
SHREVEPORT LA
71106-7231
US

IV. Provider business mailing address

463 ASHLEY RIDGE BLVD SUITE 100
SHREVEPORT LA
71106-7231
US

V. Phone/Fax

Practice location:
  • Phone: 318-221-3585
  • Fax: 318-227-9094
Mailing address:
  • Phone: 318-221-3585
  • Fax: 318-227-9094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number009735
License Number StateLA

VIII. Authorized Official

Name: MR. TIMOTHY JAMES MILLER
Title or Position: VP MANAGED CARE
Credential:
Phone: 615-665-7122