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General NPI Number Information
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NPI Number | 1700748159
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Entity Type | Individual
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Provider Name | ETHAN CALVIN
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Gender | Male
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Dates
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Enumeration Date | 11/24/2025
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Last Update Date | 11/24/2025
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Provider Practice Location Address
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Address Line | 2161 AIRLINE DR STE B
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City | BOSSIER CITY
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State | LA
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Zip | 71111-3172
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Country | US
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Telephone | 318-746-6288
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Fax | 318-746-7911
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Provider Business Mailing Address
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Address Line | 1509 DOCTORS DR
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City | BOSSIER CITY
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State | LA
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Zip | 71111-3321
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Country | US
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Telephone | 318-746-6288
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Fax | 318-746-7911
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 247200000X
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Taxonomy Name | Other Technician
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License Number | 100599
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License Number State | LA
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