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General NPI Number Information
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NPI Number | 1497937601
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Entity Type | Organization
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Legal Business Name | WALLS MEDICINE CLINIC LLC
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Dates
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Enumeration Date | 11/29/2007
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Last Update Date | 11/09/2018
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Provider Practice Location Address
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Address Line | 1801 FAIRFIELD AVE. STE 200
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City | SHREVEPORT
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State | LA
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Zip | 71101
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Country | US
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Telephone | 318-675-1800
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Fax | 318-675-1818
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Provider Business Mailing Address
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Address Line | 1801 FAIRFIELD AVE. STE 200
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City | SHREVEPORT
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State | LA
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Zip | 71101
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Country | US
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Telephone | 318-675-1800
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Fax | 318-675-1818
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Authorized Official
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Title or Position | OWNER
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Name | MR. WENDELL E. WALL
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Credential | M.D.
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Telephone | 318-675-1800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 11458R
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License Number State | LA
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