Provider Demographics
NPI:1730645201
Name:WILLIS KNIGHTON MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:WILLIS KNIGHTON MEDICAL CENTER, INC.
Other - Org Name:WK OUTPATIENT LAB SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-4544
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:
Mailing Address - Fax:
Practice Address - Street 1:2600 GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3908
Practice Address - Country:US
Practice Address - Phone:318-212-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-20
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology