Healthcare Provider Details

I. General information

NPI: 1669416491
Provider Name (Legal Business Name): NORTHWEST LOUISIANA NEPHROLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 BUCKNER ST SUITE C120
SHREVEPORT LA
71101-4440
US

IV. Provider business mailing address

1800 BUCKNER ST SUITE C120
SHREVEPORT LA
71101-4440
US

V. Phone/Fax

Practice location:
  • Phone: 318-227-8899
  • Fax: 318-222-0407
Mailing address:
  • Phone: 318-227-8899
  • Fax: 318-222-0407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: WANDA S CARTER
Title or Position: MANAGER
Credential:
Phone: 318-227-8899