Healthcare Provider Details

I. General information

NPI: 1710095690
Provider Name (Legal Business Name): BONE & JOINT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 LOUISIANA AVE
SHREVEPORT LA
71101-3910
US

IV. Provider business mailing address

1202 LOUISIANA AVE
SHREVEPORT LA
71101-3910
US

V. Phone/Fax

Practice location:
  • Phone: 318-425-8701
  • Fax:
Mailing address:
  • Phone: 318-425-8701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number09700
License Number StateLA

VIII. Authorized Official

Name: MR. WAYNE SMITH
Title or Position: ADMINISTRATOR
Credential: MANAGER
Phone: 318-425-8701