Provider Demographics
NPI:1639115132
Name:WK URGENT CARE CENTER-PIERREMONT
Entity Type:Organization
Organization Name:WK URGENT CARE CENTER-PIERREMONT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-3520
Mailing Address - Street 1:1666 E BERT KOUNS LOOP
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5714
Mailing Address - Country:US
Mailing Address - Phone:318-212-3520
Mailing Address - Fax:318-212-3525
Practice Address - Street 1:1666 E BERT KOUNS LOOP
Practice Address - Street 2:SUITE 105
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5714
Practice Address - Country:US
Practice Address - Phone:318-212-3520
Practice Address - Fax:318-212-3525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1440671Medicaid
LA1440671Medicaid