Provider Demographics
NPI:1326730573
Name:WK SWAN LAKE DIABETES & ENDOCRINOLOGY
Entity Type:Organization
Organization Name:WK SWAN LAKE DIABETES & ENDOCRINOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. VP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-716-4937
Mailing Address - Street 1:5341 AIRLINE DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111
Mailing Address - Country:US
Mailing Address - Phone:318-935-1810
Mailing Address - Fax:318-935-1867
Practice Address - Street 1:5341 AIRLINE DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111
Practice Address - Country:US
Practice Address - Phone:318-935-1810
Practice Address - Fax:318-935-1867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty