Provider Demographics
NPI:1710039896
Name:WILLIS KNIGHTON MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:WILLIS KNIGHTON MEDICAL CENTER, INC.
Other - Org Name:WILLIS KNIGHTON REHABILITATION UNIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-4384
Mailing Address - Street 1:PO BOX 32600
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71130-2600
Mailing Address - Country:US
Mailing Address - Phone:318-212-4000
Mailing Address - Fax:
Practice Address - Street 1:1111 LINE AVENUE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101
Practice Address - Country:US
Practice Address - Phone:318-212-4877
Practice Address - Fax:318-212-4192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA232273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
19T111Medicare ID - Type Unspecified