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General NPI Number Information
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NPI Number | 1376812487
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Entity Type | Organization
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Legal Business Name | GPN JACKSONVILLE LLC
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Dates
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Enumeration Date | 12/19/2011
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Last Update Date | 08/27/2012
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Provider Practice Location Address
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Address Line | 1400 BRADEN ST ER DEPT
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City | JACKSONVILLE
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State | AR
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Zip | 72076-3721
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Country | US
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Telephone | 501-985-7315
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3925
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City | SHREVEPORT
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State | LA
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Zip | 71133-3925
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Country | US
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Telephone | 800-684-0052
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | SAMUEL D HUCKABEE
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Credential |
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Telephone | 318-629-5349
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number |
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License Number State |
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