Provider Demographics
NPI:1427490937
Name:BOMBINAMD LLC
Entity type:Organization
Organization Name:BOMBINAMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUYAH
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOUD-DOCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-946-8183
Mailing Address - Street 1:4140 HOLLYWOOD AVE
Mailing Address - Street 2:SUITE B-2
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71109-7818
Mailing Address - Country:US
Mailing Address - Phone:318-946-8183
Mailing Address - Fax:
Practice Address - Street 1:4140 HOLLYWOOD AVE
Practice Address - Street 2:SUITE B-2
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-7818
Practice Address - Country:US
Practice Address - Phone:318-946-8183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15815R261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center