Healthcare Provider Details

I. General information

NPI: 1033111240
Provider Name (Legal Business Name): SOUTHSIDE FOOT CLINIC OF SHREVEPORT, INC. A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9308 MANSFIELD RD STE 100
SHREVEPORT LA
71118-3134
US

IV. Provider business mailing address

9308 MANSFIELD RD STE 100
SHREVEPORT LA
71118-3134
US

V. Phone/Fax

Practice location:
  • Phone: 318-687-6266
  • Fax: 318-683-1023
Mailing address:
  • Phone: 318-687-6266
  • Fax: 318-683-1023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5B496
License Number StateLA

VIII. Authorized Official

Name: MR. RICHARD TAYLOR HAVENS
Title or Position: PHYSICIAN/ADMINISTRATOR
Credential: D.P.M.
Phone: 318-687-6266