MEDICARE: NEW AWAKENINGS, 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	2084P0800X	Psychiatry Physician	MD204139	LA

General Provider Information

NPI Number	:	1730551052
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW AWAKENINGS, LLC

Provider Business Mailing Address
First Line	:	4440 VIKING DR
Second Line	:	SUITE 300-400
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-7511
Country	:	US
Telephone Number	:	318-584-7137
Fax Number	:

Provider Business Practice Location Address
First Line	:	4440 VIKING DR
Second Line	:	SUITE 300-400
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-7511
Country	:	US
Telephone Number	:	318-584-7137
Fax Number	:	318-584-7140

Authorized Official
Title or Position	:	OWNER
Name	:	ANSHUMAN JYOTI
Credential	:	M.D.
Telephone Number	:	818-438-9091

Provider Enumeration Date	:	10/26/2015
Last Update Date	:	10/26/2015

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