Healthcare Provider Details

I. General information

NPI: 1720468283
Provider Name (Legal Business Name): KINSEY MONTGOMERY PHLEBOTOMY/LAB ASST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2015
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7505 PINES RD SUITE 1200 D
SHREVEPORT LA
71129-3935
US

IV. Provider business mailing address

7505 PINES RD SUITE 1200 D
SHREVEPORT LA
71129-3935
US

V. Phone/Fax

Practice location:
  • Phone: 318-626-5353
  • Fax: 318-626-5353
Mailing address:
  • Phone: 318-626-5353
  • Fax: 318-626-5353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License NumberCLP.202263-LAB
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: