=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215567573
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLIOTT DENTON DOUCET CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2020
-----------------------------------------------------
Last Update Date | 01/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1541 KINGS HWY
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71103-4228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-626-0000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4119 BALTIMORE AVE
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71106-1421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-294-0968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 211568
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------