Healthcare Provider Details

I. General information

NPI: 1700384831
Provider Name (Legal Business Name): ZODIAC HOLDING GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 01/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3611 GREENWAY PL
SHREVEPORT LA
71105-2011
US

IV. Provider business mailing address

3611 GREENWAY PL
SHREVEPORT LA
71105-2011
US

V. Phone/Fax

Practice location:
  • Phone: 318-459-8927
  • Fax:
Mailing address:
  • Phone: 318-459-8927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: VAN BIVENS
Title or Position: CEO/SOLE MEMBER
Credential: LCSW
Phone: 318-459-8927