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General NPI Number Information
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NPI Number | 1982676771
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Entity Type | Organization
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Legal Business Name | SHREVEPORT ENDOSCOPY CENTER, A MEDICAL CORPORATION
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Dates
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Enumeration Date | 02/06/2006
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Last Update Date | 08/12/2022
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Provider Practice Location Address
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Address Line | 3217 MABEL ST
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City | SHREVEPORT
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State | LA
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Zip | 71103-4022
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Country | US
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Telephone | 318-631-0072
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Fax | 318-213-4979
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Provider Business Mailing Address
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Address Line | 3217 MABEL ST
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City | SHREVEPORT
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State | LA
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Zip | 71103-4022
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Country | US
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Telephone | 318-631-0072
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Fax | 318-213-4979
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SATHYA JAGANMOHAN
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Credential | M.D.
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Telephone | 318-631-0072
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0800X
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Taxonomy Name | Endoscopy Clinic/Center
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License Number | 50
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License Number State | LA
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