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General NPI Number Information
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NPI Number | 1205022647
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Entity Type | Organization
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Legal Business Name | JCT MEDICAL CONSULTING
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Dates
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Enumeration Date | 09/19/2007
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Last Update Date | 04/29/2009
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Provider Practice Location Address
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Address Line | 460 ASHLEY RIDGE BLVD STE 500
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City | SHREVEPORT
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State | LA
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Zip | 71106-7228
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Country | US
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Telephone | 318-212-1610
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Fax | 866-455-7515
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Provider Business Mailing Address
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Address Line | 460 ASHLEY RIDGE BLVD STE 500
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City | SHREVEPORT
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State | LA
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Zip | 71106-7228
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Country | US
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Telephone | 318-212-1610
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Fax | 866-455-7515
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. RUSSELL W. TYNES
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Credential | MD
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Telephone | 318-212-1610
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 016884
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License Number State | LA
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