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General NPI Number Information
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NPI Number | 1548404361
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Entity Type | Organization
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Legal Business Name | OVERTON BROOKS VA
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Dates
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Enumeration Date | 04/23/2009
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Last Update Date | 04/23/2009
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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 | 4855 AIRLINE DR APT 37D
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City | BOSSIER CITY
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State | LA
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Zip | 71111-6652
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Country | US
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Telephone | 318-332-1589
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Fax |
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Authorized Official
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Title or Position | RADIATION THERAPIST
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Name | WAYLON MALMAY
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Credential | BSRT (R) (T)
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Telephone | 318-332-1589
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 286500000X
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Taxonomy Name | Military Hospital
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License Number |
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License Number State |
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