Provider Demographics
NPI:1326093782
Name:WILLIS KNIGHTON MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:WILLIS KNIGHTON MEDICAL CENTER, INC.
Other - Org Name:HOME HEALTH DEPARTMANT WILLIS KNIGHTON HOSPITAL INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR DECISION SUPPORT
Authorized Official - Prefix:
Authorized Official - First Name:MARY JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-4384
Mailing Address - Street 1:PO BOX 32600
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71130-2600
Mailing Address - Country:US
Mailing Address - Phone:318-212-4544
Mailing Address - Fax:318-212-4192
Practice Address - Street 1:3300 ALBERT L BICKNELL DR
Practice Address - Street 2:SUITE 4
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3903
Practice Address - Country:US
Practice Address - Phone:318-212-4180
Practice Address - Fax:318-212-4382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA65251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1400564Medicaid
LA33562OtherBLUE CROSS/BLUE SHIELD
LA1400564Medicaid