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General NPI Number Information
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NPI Number | 1285925982
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Entity Type | Organization
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Legal Business Name | OVERTON BROOKS VAMC
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Dates
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Enumeration Date | 04/28/2011
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Last Update Date | 04/28/2011
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Provider Practice Location Address
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Address Line | 510 E STONER AVE
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City | SHREVEPORT
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State | LA
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Zip | 71101-4243
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Country | US
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Telephone | 318-221-8411
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Fax |
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Provider Business Mailing Address
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Address Line | 510 E STONER AVE
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City | SHREVEPORT
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State | LA
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Zip | 71101-4243
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Country | US
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Telephone | 318-221-8411
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Fax |
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Authorized Official
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Title or Position | KINESIOTHERAPIST
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Name | MR. CHARLES DAI-TRIEU CAO
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Credential | REGISTERED KT
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Telephone | 318-221-8411
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State | NULL
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