MEDICARE: TATE & BARNES WALK IN CLINIC, 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	261QU0200X	Urgent Care Clinic/Center		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

General Provider Information

NPI Number	:	1306177076
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TATE & BARNES WALK IN CLINIC, LLC

Provider Business Mailing Address
First Line	:	PO BOX 29591
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71149-9591
Country	:	US
Telephone Number	:	318-603-0440
Fax Number	:

Provider Business Practice Location Address
First Line	:	6823 PINES RD
Second Line	:	SUITE A
City	:	SHREVEPORT
State	:	LA
Zip	:	71129-5205
Country	:	US
Telephone Number	:	318-603-0440
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. JAMESETTA WARD TATE
Credential	:	M.D.
Telephone Number	:	318-603-0440

Provider Enumeration Date	:	01/20/2010
Last Update Date	:	01/20/2010

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