MEDICARE: MMO OF SHREVEPORT, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)		LA

General Provider Information

NPI Number	:	1124067145
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MMO OF SHREVEPORT, LLC

Provider Business Mailing Address
First Line	:	728 NORTH BLVD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70802-5724
Country	:	US
Telephone Number	:	225-293-6774
Fax Number	:	225-291-9299

Provider Business Practice Location Address
First Line	:	3341 YOUREE DR
Second Line	:	SUITE 102
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-2149
Country	:	US
Telephone Number	:	318-688-6228
Fax Number	:	318-688-6466

Authorized Official
Title or Position	:	CEO
Name	:	MR. ROBERT L MILLER
Credential	:
Telephone Number	:	225-293-6774

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	10/03/2008

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Directions to “MMO OF SHREVEPORT, LLC ” Practice Location

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