Healthcare Provider Details

I. General information

NPI: 1720018492
Provider Name (Legal Business Name): COMPLETE VITAL CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 BERT KOUNS INDUSTRIAL LOOP SUITE 116
SHREVEPORT LA
71118-3132
US

IV. Provider business mailing address

411 ASHLEY RIDGE BLVD
SHREVEPORT LA
71106-7229
US

V. Phone/Fax

Practice location:
  • Phone: 318-686-9995
  • Fax: 318-686-9997
Mailing address:
  • Phone: 318-747-9977
  • Fax: 318-747-9994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number4863-IR
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number4863-IR
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number4863-IR
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number4863-IR
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number4863-IR
License Number StateLA
# 6
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number4863-IR
License Number StateLA
# 7
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number4863-IR
License Number StateLA
# 8
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number4863-IR
License Number StateLA
# 9
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number4863-IR
License Number StateLA
# 10
Primary TaxonomyY
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number4863-IR
License Number StateLA

VIII. Authorized Official

Name: TED GARDINER
Title or Position: PRESIDENT
Credential:
Phone: 318-686-9995