=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497410476
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KDE ENTERPRISES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2021
-----------------------------------------------------
Last Update Date | 11/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7505 PINES RD STE 1295
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71129-3923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-402-4434
-----------------------------------------------------
Fax | 318-383-6686
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7505 PINES RD STE 1295
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71129-3923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-402-4434
-----------------------------------------------------
Fax | 318-383-6686
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | RICKEY EVANS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 318-300-4623
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------