Provider Demographics
NPI:1194784173
Name:MEDICAL INFUSION THERAPY OF LA
Entity type:Organization
Organization Name:MEDICAL INFUSION THERAPY OF LA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOOGENDYK
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:318-741-1009
Mailing Address - Street 1:1525 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3321
Mailing Address - Country:US
Mailing Address - Phone:318-741-1009
Mailing Address - Fax:318-741-1842
Practice Address - Street 1:1525 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3321
Practice Address - Country:US
Practice Address - Phone:318-741-1009
Practice Address - Fax:318-741-1842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-20
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4428 IR261QI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1264733Medicaid
LA1264733Medicaid