Provider Demographics
NPI:1144491614
Name:AMBULATORY SURGERY CENTER OF LOUISIANA
Entity type:Organization
Organization Name:AMBULATORY SURGERY CENTER OF LOUISIANA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JANNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CRUEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-0552
Mailing Address - Street 1:385 BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:BLDG 300
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-8124
Mailing Address - Country:US
Mailing Address - Phone:318-212-0552
Mailing Address - Fax:318-212-0557
Practice Address - Street 1:385 BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:BLDG 300
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-8124
Practice Address - Country:US
Practice Address - Phone:318-212-0552
Practice Address - Fax:318-212-0557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA164261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA=========OtherEIN
LA15026Medicare PIN
LA19C0001119Medicare UPIN