Provider Demographics
NPI:1548447568
Name:KITTY A ROARK.
Entity type:Organization
Organization Name:KITTY A ROARK.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KITTY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-868-5851
Mailing Address - Street 1:855 PIERREMONT RD STE 126
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-2074
Mailing Address - Country:US
Mailing Address - Phone:318-868-5851
Mailing Address - Fax:318-798-3348
Practice Address - Street 1:855 PIERREMONT RD STE 126
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-2074
Practice Address - Country:US
Practice Address - Phone:318-868-5851
Practice Address - Fax:318-798-3348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA00193754335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA=========AOtherBLUE CROSS BLUE SHIELD
LA0690890001Medicare NSC