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General NPI Number Information
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NPI Number | 1144454646
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Entity Type | Organization
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Legal Business Name | SHREVEPORT PRIME CARE INC
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Dates
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Enumeration Date | 05/12/2009
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Last Update Date | 05/12/2009
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Provider Practice Location Address
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Address Line | 1513 LINE AVE # 240
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City | SHREVEPORT
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State | LA
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Zip | 71101-4621
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Country | US
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Telephone | 318-402-2333
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Fax |
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Provider Business Mailing Address
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Address Line | 1513 LINE AVE # 240
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City | SHREVEPORT
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State | LA
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Zip | 71101-4621
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DEBBIE M JURGELSKY
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Credential | MD
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Telephone | 318-402-2333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 017289
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License Number State | LA
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