Healthcare Provider Details

I. General information

NPI: 1780848580
Provider Name (Legal Business Name): WK ARK-LA-TEX NEONATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 BERT KOUNS LOOP ROOM 215
SHREVEPORT LA
71118-3119
US

IV. Provider business mailing address

1202 LOUISIANA AVE
SHREVEPORT LA
71101-3910
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-5970
  • Fax:
Mailing address:
  • Phone: 318-212-8946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GREG J GAVIN
Title or Position: NETWORK/ADMINISTRATOR
Credential:
Phone: 318-212-4571