Provider Demographics
NPI:1144473224
Name:COLLINS, GAYLORD (CP)
Entity type:Individual
Prefix:MR
First Name:GAYLORD
Middle Name:
Last Name:COLLINS
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 SHREVEPORT HWY
Mailing Address - Street 2:APT 275
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-2006
Mailing Address - Country:US
Mailing Address - Phone:601-842-7780
Mailing Address - Fax:
Practice Address - Street 1:2495 SHREVEPORT HWY
Practice Address - Street 2:BLD 2 RM 242
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71306-9004
Practice Address - Country:US
Practice Address - Phone:318-473-0010
Practice Address - Fax:318-483-5154
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CP003397224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist