Healthcare Provider Details

I. General information

NPI: 1700929874
Provider Name (Legal Business Name): THE PLASTIC SURGERY CENTER LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 BERT KOUNS IND. LOOP, BLDG 100
SHREVEPORT LA
71106-8124
US

IV. Provider business mailing address

385 BERT KOUNS IND. LOOP, BLDG 100
SHREVEPORT LA
71106-8124
US

V. Phone/Fax

Practice location:
  • Phone: 318-221-1629
  • Fax:
Mailing address:
  • Phone: 318-221-1629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. FORREST WALL
Title or Position: OWNER
Credential: M.D.
Phone: 318-221-1629