Provider Demographics
NPI:1306906730
Name:THE ASTHMA ALLERGY CLINIC
Entity type:Organization
Organization Name:THE ASTHMA ALLERGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:BOGGS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-221-3584
Mailing Address - Street 1:PO BOX 53407
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-3407
Mailing Address - Country:US
Mailing Address - Phone:318-221-3584
Mailing Address - Fax:318-227-9094
Practice Address - Street 1:1717 E BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:SUITE B
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5561
Practice Address - Country:US
Practice Address - Phone:318-221-3584
Practice Address - Fax:318-227-9094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD 009735174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1122475Medicaid
LAB62683Medicare UPIN
LA5B057Medicare ID - Type Unspecified