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General NPI Number Information
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NPI Number | 1144660028
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Entity Type | Organization
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Legal Business Name | RESURRECTION CENTER OF LOUISIANA
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Dates
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Enumeration Date | 06/25/2013
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Last Update Date | 06/25/2013
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Provider Practice Location Address
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Address Line | 515 E WASHINGTON ST SUITE B
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City | SHREVEPORT
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State | LA
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Zip | 71104-3658
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Country | US
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Telephone | 318-455-7275
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Fax | 318-658-9134
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Provider Business Mailing Address
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Address Line | 515 E WASHINGTON ST SUITE B
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City | SHREVEPORT
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State | LA
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Zip | 71104-3658
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Country | US
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Telephone | 318-455-7275
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Fax | 318-658-9134
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Authorized Official
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Title or Position | OWNER
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Name | MS. OMISHA MICHELLE BANKS
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Credential |
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Telephone | 318-455-7275
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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