Healthcare Provider Details

I. General information

NPI: 1962448977
Provider Name (Legal Business Name): VICKI S COBB MD & WILLIS-KNIGHTON MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4707 PALMETTO RD
BENTON LA
71006-9712
US

IV. Provider business mailing address

4707 PALMETTO RD
BENTON LA
71006-9712
US

V. Phone/Fax

Practice location:
  • Phone: 318-965-9644
  • Fax: 318-965-9640
Mailing address:
  • Phone: 318-965-9644
  • Fax: 318-965-9640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GREG J. GAVIN
Title or Position: NETWORK ADMINISTRATOR
Credential:
Phone: 318-965-9644