Healthcare Provider Details

I. General information

NPI: 1114256476
Provider Name (Legal Business Name): WK SHREVEPORT CENTER FOR GERIATRIC HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2009
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2508 BERT KOUNS LOOP SUITE 303
SHREVEPORT LA
71118-3133
US

IV. Provider business mailing address

2508 BERT KOUNS LOOP SUITE 303
SHREVEPORT LA
71118-3133
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-5850
  • Fax: 318-212-5855
Mailing address:
  • Phone: 318-212-5850
  • Fax: 318-212-5855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

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