Healthcare Provider Details

I. General information

NPI: 1760939987
Provider Name (Legal Business Name): WK ALLERGY AND ASTHMA CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2016
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 HOSPITAL DR STE 345
BOSSIER CITY LA
71111-2194
US

IV. Provider business mailing address

2300 HOSPITAL DR SUITE 110
BOSSIER CITY LA
71111-2394
US

V. Phone/Fax

Practice location:
  • Phone: 318-227-7946
  • Fax:
Mailing address:
  • Phone: 318-227-7946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License Number
License Number State

VIII. Authorized Official

Name: GREG J GAVIN
Title or Position: MANAGED CARE CREDENTIALING
Credential:
Phone: 318-212-8951