Healthcare Provider Details

I. General information

NPI: 1053889261
Provider Name (Legal Business Name): KENNETH WAYNE EAGLIN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 01/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 SAINT JOHN ST
LAFAYETTE LA
70501
US

IV. Provider business mailing address

1301 YOUREE DR
SHREVEPORT LA
71101-5117
US

V. Phone/Fax

Practice location:
  • Phone: 337-261-2300
  • Fax: 337-261-9080
Mailing address:
  • Phone: 318-675-0804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: