Basic Information
| Provider Information | |||||||||
| NPI: | 1952456311 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER | ||||||||
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| OtherOrganizationName: | LSUHSC-S DIALYSIS UNIT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 KINGS HWY | ||||||||
| Address2: | DIALYSIS UNIT | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186755000 | ||||||||
| FaxNumber: | 3186755666 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 KINGS HWY | ||||||||
| Address2: | DIALYSIS UNIT | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186755000 | ||||||||
| FaxNumber: | 3186755666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 10/25/2007 | ||||||||
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| AuthorizedOfficialLastName: | SOTAK | ||||||||
| AuthorizedOfficialFirstName: | MELANIE | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 3186757737 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MHSA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 005 | LA | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.