Provider Demographics
NPI:1467855361
Name:WK SOUTH AUDIOLOGY CENTER
Entity Type:Organization
Organization Name:WK SOUTH AUDIOLOGY CENTER
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:318-212-8780
Mailing Address - Street 1:2530 BERT KOUN LOOP
Mailing Address - Street 2:SUITE 131
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3132
Mailing Address - Country:US
Mailing Address - Phone:318-212-5488
Mailing Address - Fax:318-212-5403
Practice Address - Street 1:2530 BERT KOUN LOOP
Practice Address - Street 2:SUITE 131
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3132
Practice Address - Country:US
Practice Address - Phone:318-212-5488
Practice Address - Fax:318-212-5403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-06
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty