Healthcare Provider Details

I. General information

NPI: 1548404361
Provider Name (Legal Business Name): OVERTON BROOKS VA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 04/23/2009
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

4855 AIRLINE DR APT 37D
BOSSIER CITY LA
71111-6652
US

V. Phone/Fax

Practice location:
  • Phone: 318-221-8411
  • Fax:
Mailing address:
  • Phone: 318-332-1589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number
License Number State

VIII. Authorized Official

Name: WAYLON MALMAY
Title or Position: RADIATION THERAPIST
Credential: BSRT (R) (T)
Phone: 318-332-1589