Provider Demographics
NPI:1861915415
Name:INTEGRA HEALTH SERVICES PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:INTEGRA HEALTH SERVICES PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:F
Authorized Official - Last Name:CHICO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-780-6230
Mailing Address - Street 1:PO BOX 53032
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-3032
Mailing Address - Country:US
Mailing Address - Phone:318-798-4606
Mailing Address - Fax:318-798-4601
Practice Address - Street 1:1110 RINGGOLD AVE STE B
Practice Address - Street 2:
Practice Address - City:COUSHATTA
Practice Address - State:LA
Practice Address - Zip Code:71019-9004
Practice Address - Country:US
Practice Address - Phone:318-798-4606
Practice Address - Fax:318-798-4601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.11956R282E00000X, 283X00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No282E00000XHospitalsLong Term Care HospitalGroup - Single Specialty
No283X00000XHospitalsRehabilitation Hospital