Healthcare Provider Details

I. General information

NPI: 1992731301
Provider Name (Legal Business Name): WILLIS KNIGHTON MEDICAL CENTER & M R MANCHANDIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2706 SHED RD
BOSSIER CITY LA
71111-3348
US

IV. Provider business mailing address

2706 SHED RD
BOSSIER CITY LA
71111-3348
US

V. Phone/Fax

Practice location:
  • Phone: 318-747-5272
  • Fax: 318-746-9669
Mailing address:
  • Phone: 318-747-5272
  • Fax: 318-746-9669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: GREG J GAVIN
Title or Position: NETWORK ADMINISTRATOR
Credential:
Phone: 318-747-5272