Healthcare Provider Details

I. General information

NPI: 1144267451
Provider Name (Legal Business Name): WILLIS KNIGHTON MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 KINGS HWY
SHREVEPORT LA
71103-3922
US

IV. Provider business mailing address

PO BOX 32600
SHREVEPORT LA
71130-2600
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-8200
  • Fax: 318-212-8220
Mailing address:
  • Phone: 318-212-8200
  • Fax: 318-212-8220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number232
License Number StateLA

VIII. Authorized Official

Name: STACY H ALEXANDER
Title or Position: CONTROLLER
Credential:
Phone: 318-212-4877