Healthcare Provider Details

I. General information

NPI: 1346537412
Provider Name (Legal Business Name): OVERTON BROOKS VETERANS HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 07/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E STONER AVE
SHREVEPORT LA
71101-4243
US

IV. Provider business mailing address

510 E STONER AVE
SHREVEPORT LA
71101-4243
US

V. Phone/Fax

Practice location:
  • Phone: 318-221-8411
  • Fax: 318-429-5727
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License NumberZ20148
License Number StateLA

VIII. Authorized Official

Name: TODD MOORE
Title or Position: ASST. ADMINSTRATOR
Credential:
Phone: 318-221-2411