Provider Demographics
NPI:1215216494
Name:WK PEDIATRIC HEALTHCARE ASSOCIATES
Entity Type:Organization
Organization Name:WK PEDIATRIC HEALTHCARE ASSOCIATES
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:318-242-4232
Mailing Address - Street 1:1717 E BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5561
Mailing Address - Country:US
Mailing Address - Phone:318-212-2920
Mailing Address - Fax:318-212-2910
Practice Address - Street 1:1717 E BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5561
Practice Address - Country:US
Practice Address - Phone:318-212-2920
Practice Address - Fax:318-212-2910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-05
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty