Provider Demographics
NPI:1114256476
Name:WK SHREVEPORT CENTER FOR GERIATRIC HEALTH
Entity Type:Organization
Organization Name:WK SHREVEPORT CENTER FOR GERIATRIC HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NETWORK ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-4232
Mailing Address - Street 1:2508 BERT KOUNS LOOP
Mailing Address - Street 2:SUITE 303
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3133
Mailing Address - Country:US
Mailing Address - Phone:318-212-5850
Mailing Address - Fax:318-212-5855
Practice Address - Street 1:2508 BERT KOUNS LOOP
Practice Address - Street 2:SUITE 303
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3133
Practice Address - Country:US
Practice Address - Phone:318-212-5850
Practice Address - Fax:318-212-5855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-16
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5DL73OtherMEDICARE PTAN
LA1818798Medicaid