Healthcare Provider Details

I. General information

NPI: 1245215706
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: 12/07/2005
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9308 MANSFIELD RD SUITE 300
SHREVEPORT LA
71118-3134
US

IV. Provider business mailing address

9308 MANSFIELD RD SUITE 300
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 Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number33
License Number StateLA

VIII. Authorized Official

Name: DR. RICHARD TAYLOR HAVENS
Title or Position: ADMINISTRATOR/PHYSICIAN
Credential: DPM
Phone: 318-687-6266