Healthcare Provider Details

I. General information

NPI: 1871728956
Provider Name (Legal Business Name): WK REGIONAL PERINATAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 02/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2508 BERT KOUNS INDUSTRIAL LOOP SUITE 210
SHREVEPORT LA
71118-3133
US

IV. Provider business mailing address

2508 BERT KOUNS INDUSTRIAL LOOP SUITE 210
SHREVEPORT LA
71118-3133
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-5860
  • Fax: 318-212-5865
Mailing address:
  • Phone: 318-212-5860
  • Fax: 318-212-5865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GREG J. GAVIN
Title or Position: NETWORK ADMINISTRATOR
Credential:
Phone: 318-212-8780