Basic Information
| Provider Information | |||||||||
| NPI: | 1750345419 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOSSIER SPECIALTY HOSPITAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2105 AIRLINE DR | ||||||||
| Address2: | |||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711113105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3185492011 | ||||||||
| FaxNumber: | 3185492077 | ||||||||
| Practice Location | |||||||||
| Address1: | 2105 AIRLINE DR | ||||||||
| Address2: | |||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711113105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3185492011 | ||||||||
| FaxNumber: | 3185492077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HUFFMAN | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | SUE | ||||||||
| AuthorizedOfficialTitleorPosition: | VP MANAGED CARE SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 6365492384 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MHA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 284300000X | 29570 | LA | Y | Hospitals | Special Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1702650 | 05 | LA | MEDICAID |