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General NPI Number Information
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NPI Number | 1477242196
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Entity Type | Organization
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Legal Business Name | NOVA VITAL IOP LLC
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Dates
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Enumeration Date | 05/08/2023
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Last Update Date | 04/05/2024
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Provider Practice Location Address
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Address Line | 850 MARGARET PL
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City | SHREVEPORT
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State | LA
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Zip | 71101-4521
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Country | US
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Telephone | 318-268-6101
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Fax |
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Provider Business Mailing Address
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Address Line | 8520 BUSINESS PARK DR
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City | SHREVEPORT
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State | LA
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Zip | 71105-5654
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Country | US
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Telephone | 318-268-6101
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Fax |
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Authorized Official
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Title or Position | CONTROLLER
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Name | MRS. MALLORY MACISAAC
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Credential |
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Telephone | 318-268-6101
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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