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General NPI Number Information
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NPI Number | 1013217595
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Entity Type | Organization
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Legal Business Name | SOUTH SHREVEPORT FAMILY MEDICINE, LLC
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Dates
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Enumeration Date | 10/29/2010
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Last Update Date | 10/05/2022
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Provider Practice Location Address
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Address Line | 8660 FERN AVE STE 105
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City | SHREVEPORT
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State | LA
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Zip | 71105-5657
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Country | US
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Telephone | 318-797-0009
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Fax | 318-797-0092
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Provider Business Mailing Address
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Address Line | 530 RED BARON DR
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City | SHREVEPORT
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State | LA
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Zip | 71115-3052
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Country | US
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Telephone | 318-349-6728
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Fax |
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Authorized Official
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Title or Position | FNP
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Name | JON CHARLES BARNES
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Credential | FNP
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Telephone | 318-349-6728
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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