Provider Demographics
NPI:1366593022
Name:SNELLS LIMBS & BRACES OF SHREVEPORT LLC
Entity type:Organization
Organization Name:SNELLS LIMBS & BRACES OF SHREVEPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:N
Authorized Official - Last Name:MASSEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:318-424-4167
Mailing Address - Street 1:1833 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4611
Mailing Address - Country:US
Mailing Address - Phone:318-424-4167
Mailing Address - Fax:
Practice Address - Street 1:1404 JACKSON ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-6931
Practice Address - Country:US
Practice Address - Phone:318-443-6391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA27624OtherBLUE CROSS SUPPLIER NUMBE
LA1909734Medicaid
LA27624OtherBLUE CROSS SUPPLIER NUMBE