Provider Demographics
NPI:1407888209
Name:WK BUTLER-ABSHIRE MEDICAL CLINIC
Entity Type:Organization
Organization Name:WK BUTLER-ABSHIRE MEDICAL CLINIC
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:318-624-0554
Mailing Address - Street 1:PO BOX 271
Mailing Address - Street 2:
Mailing Address - City:HAYNESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71038-0271
Mailing Address - Country:US
Mailing Address - Phone:318-624-0554
Mailing Address - Fax:318-624-3782
Practice Address - Street 1:926 FRANCES DR
Practice Address - Street 2:
Practice Address - City:HAYNESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71038-6100
Practice Address - Country:US
Practice Address - Phone:318-624-0554
Practice Address - Fax:318-624-3782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1944327Medicaid
AK136859729Medicaid
LA1944327Medicaid
AK136859729Medicaid