=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255624169
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WK ORTHOPEDIC SPECIALTY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2011
-----------------------------------------------------
Last Update Date | 06/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2551 GREENWOOD RD STE 130
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71103-3984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-212-8681
-----------------------------------------------------
Fax | 318-212-8685
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2551 GREENWOOD RD STE 130
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71103-3984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-212-8681
-----------------------------------------------------
Fax | 318-212-8685
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NETWORK ADMINSTRATOR
-----------------------------------------------------
Name | GREG J GAVIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 318-212-4232
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------