=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528133055
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J.K.S. PEDIATRICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2006
-----------------------------------------------------
Last Update Date | 07/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 740 KEYSER AVE SUITE A-3
-----------------------------------------------------
City | NATCHITOCHES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71457-6037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-238-5040
-----------------------------------------------------
Fax | 318-357-8842
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 740 KEYSER AVE SUITE A-3
-----------------------------------------------------
City | NATCHITOCHES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71457-6037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-238-5040
-----------------------------------------------------
Fax | 318-357-8842
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JORGE W BLACK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 318-238-5040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 201180
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------