Healthcare Provider Details

I. General information

NPI: 1639349681
Provider Name (Legal Business Name): DELTA MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 BUCKNER ST STE B210
SHREVEPORT LA
71101-4438
US

IV. Provider business mailing address

1800 BUCKNER ST STE B210
SHREVEPORT LA
71101-4438
US

V. Phone/Fax

Practice location:
  • Phone: 318-459-1600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number11385
License Number StateLA

VIII. Authorized Official

Name: MRS. DORIS MITCHELL
Title or Position: PRESIDENT/CEO
Credential:
Phone: 318-459-1600