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General NPI Number Information
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NPI Number | 1053607937
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Entity Type | Organization
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Legal Business Name | WK CARE FOR KIDS CLINIC
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Dates
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Enumeration Date | 06/20/2011
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Last Update Date | 12/18/2012
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Provider Practice Location Address
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Address Line | 870 OLIVE ST
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City | SHREVEPORT
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State | LA
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Zip | 71104-2159
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Country | US
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Telephone | 318-629-0480
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Fax | 318-629-0483
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Provider Business Mailing Address
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Address Line | 870 OLIVE ST
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City | SHREVEPORT
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State | LA
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Zip | 71104-2159
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Country | US
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Telephone | 318-629-0480
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Fax | 318-629-0483
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Authorized Official
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Title or Position | NETWORK ADMINISTRATOR
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Name | MR. GREG J. GAVIN
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Credential |
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Telephone | 318-212-4232
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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