Provider Demographics
NPI:1902138498
Name:ENDOVASCULAR TECHNOLOGIES, LLC
Entity Type:Organization
Organization Name:ENDOVASCULAR TECHNOLOGIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BRITTON
Authorized Official - Last Name:EAVES
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:318-752-2328
Mailing Address - Street 1:PO BOX 1760
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71166-1760
Mailing Address - Country:US
Mailing Address - Phone:318-752-2328
Mailing Address - Fax:318-746-0160
Practice Address - Street 1:2300 HOSPITAL DR
Practice Address - Street 2:SUITE 450
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2394
Practice Address - Country:US
Practice Address - Phone:318-752-2328
Practice Address - Fax:318-746-0160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021588207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty