MEDICARE: REPUNDA MIMS BALL

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	372600000X	Adult Companion	10737	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194945360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REPUNDA MIMS BALL

Provider Business Mailing Address
First Line	:	7505 PINES RD STE.1104
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71129
Country	:	US
Telephone Number	:	318-671-1772
Fax Number	:	318-671-1774

Provider Business Practice Location Address
First Line	:	7505 PINES RD STE 1104
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71129-3900
Country	:	US
Telephone Number	:	318-671-1772
Fax Number	:	318-671-1774

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2007
Last Update Date	:	07/09/2007

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1255464566 — MS. EMILY ELIZABETH BAILEY LPC
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1760738801 — TIFFANY GEORGE-ISAAC NP
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1235539644 — ENVISION COUNSELING SERVICES LLC
Practice Location Address:

7505 PINES RD STE 1230
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1821471921 — ZELLA Y. GREEN
Practice Location Address:

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1609242320 — BARBARA MAIDEN LMSW
Practice Location Address:

7505 PINES RD STE 1200I
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Directions to “ REPUNDA MIMS BALL ” Practice Location

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