=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376710392
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CG CONCIERGE & IN HOME PERSONAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2008
-----------------------------------------------------
Last Update Date | 05/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 718 W 71ST ST
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71106-3502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-382-5711
-----------------------------------------------------
Fax | 318-688-6276
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 65131
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71136-5131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-382-5711
-----------------------------------------------------
Fax | 318-688-6276
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ OPERATOR
-----------------------------------------------------
Name | MR. CLYDE L GOSEY JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-382-5711
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------