=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548618556
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RODERICK CASEY EMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2016
-----------------------------------------------------
Last Update Date | 05/31/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2924 KNIGHT ST SUITE 426
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71105-2415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-754-3560
-----------------------------------------------------
Fax | 318-779-0439
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2924 KNIGHT ST SUITE 426
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71105-2415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-754-3560
-----------------------------------------------------
Fax | 318-779-0439
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 146L00000X
-----------------------------------------------------
Taxonomy Name | Paramedic
-----------------------------------------------------
License Number | 146L00000X
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------