Provider Demographics
NPI:1497047963
Name:WK SOUTH ORTHOPEDIC CLINIC
Entity Type:Organization
Organization Name:WK SOUTH ORTHOPEDIC 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:318-212-4232
Mailing Address - Street 1:2520 BERT KOUNS LOOP
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3130
Mailing Address - Country:US
Mailing Address - Phone:318-212-5886
Mailing Address - Fax:318-212-5889
Practice Address - Street 1:2520 BERT KOUNS LOOP
Practice Address - Street 2:SUITE 105
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3130
Practice Address - Country:US
Practice Address - Phone:318-212-5886
Practice Address - Fax:318-212-5889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty