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General NPI Number Information
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NPI Number | 1831283670
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Entity Type | Organization
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Legal Business Name | ALLEGIANCE HEALTH CENTER OF RUSTON, LLC
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Dates
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Enumeration Date | 10/03/2006
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Last Update Date | 04/16/2008
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Provider Practice Location Address
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Address Line | 1401 EZELLE ST
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City | RUSTON
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State | LA
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Zip | 71270-7218
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Country | US
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Telephone | 318-255-8085
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Fax | 318-251-5146
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Provider Business Mailing Address
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Address Line | 504 TEXAS ST STE 200
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City | SHREVEPORT
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State | LA
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Zip | 71101-3526
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Country | US
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Telephone | 318-226-8202
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Fax | 318-226-8205
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Authorized Official
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Title or Position | CEO PRESIDENT
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Name | MR. ROCK BORDELON
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Credential |
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Telephone | 318-226-8202
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 283Q00000X
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Taxonomy Name | Psychiatric Hospital
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License Number |
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License Number State |
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Legacy Identifiers
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Identifier #1
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Identifier Code | 1710831
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Identifier Type | MEDICAID
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Identifier State | LA
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Identifier Issuer |
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Proprietary Identifiers Ever Reported
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Identifier #1
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Identifier Code | 1710831
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Identifier Type | MEDICAID
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Identifier State | LA
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Identifier Issuer |
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