Provider Demographics
NPI:1497937601
Name:WALLS MEDICINE CLINIC LLC
Entity Type:Organization
Organization Name:WALLS MEDICINE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:E
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-675-1800
Mailing Address - Street 1:1801 FAIRFIELD AVE. STE 200
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101
Mailing Address - Country:US
Mailing Address - Phone:318-675-1800
Mailing Address - Fax:318-675-1818
Practice Address - Street 1:1801 FAIRFIELD AVE. STE 200
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101
Practice Address - Country:US
Practice Address - Phone:318-675-1800
Practice Address - Fax:318-675-1818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11458R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1663841Medicaid
LA5DB99Medicare PIN
LA1663841Medicaid