Healthcare Provider Details

I. General information

NPI: 1306823596
Provider Name (Legal Business Name): WK NORTH ORTHOPEDIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 06/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2751 ALBERT L BICKNELL DR SUITE 1-B
SHREVEPORT LA
71103-3920
US

IV. Provider business mailing address

1202 LOUISIANA AVE
SHREVEPORT LA
71101-3910
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-8776
  • Fax: 318-212-8774
Mailing address:
  • Phone: 318-212-8776
  • Fax: 318-212-8774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: GREG J GAVIN
Title or Position: NETWORK ADMINISTRATOR
Credential:
Phone: 318-212-4232