Healthcare Provider Details

I. General information

NPI: 1184033854
Provider Name (Legal Business Name): ARKLATEX FERTILITY AND REPRODUCTIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2014
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 GREENWOOD RD SUITE A
SHREVEPORT LA
71103-4010
US

IV. Provider business mailing address

2401 GREENWOOD RD SUITE A
SHREVEPORT LA
71103-4010
US

V. Phone/Fax

Practice location:
  • Phone: 318-841-5800
  • Fax: 318-841-5817
Mailing address:
  • Phone: 318-841-5800
  • Fax: 318-841-5817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAP0799
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code261QA0006X
TaxonomyAmbulatory Fertility Facility
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID VANDERMOLEN
Title or Position: DIRECTOR
Credential: M.D.
Phone: 318-841-5800