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? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 291U00000X | Laboratories | Clinical Medical Laboratory | |
No | 261QR0200X | Ambulatory Health Care Facilities | Clinic/Center | Radiology |