Individual
REPUNDA MIMS BALL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
7505 PINES RD STE 1104, SHREVEPORT, LA 71129-3900
(318) 671-1772
(318) 671-1774
Mailing address
7505 PINES RD STE.1104, SHREVEPORT, LA 71129
(318) 671-1772
(318) 671-1774
Taxonomy
Speciality
Code
Description
License number
State
372600000X
Adult Companion
Primary
10737
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1172057
—
LA
05
—
1178969
—
LA
05
—
1542946
—
LA
05
—
1545180
—
LA
Enumeration date
04/27/2007
Last updated
07/09/2007
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