Provider Demographics
NPI:1194279471
Name:BROOMSEY, KIERON RENARD (LCM)
Entity type:Individual
Prefix:MR
First Name:KIERON
Middle Name:RENARD
Last Name:BROOMSEY
Suffix:
Gender:M
Credentials:LCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 BENTON ROAD
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111
Mailing Address - Country:US
Mailing Address - Phone:318-422-4459
Mailing Address - Fax:
Practice Address - Street 1:1434 HAWN AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107
Practice Address - Country:US
Practice Address - Phone:318-422-4459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-04
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator