Provider Demographics
NPI:1962447052
Name:WK RIVER CITIES INTERVENTIONAL PAIN
Entity Type:Organization
Organization Name:WK RIVER CITIES INTERVENTIONAL PAIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NETWORK ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-8085
Mailing Address - Street 1:1811 E BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5740
Mailing Address - Country:US
Mailing Address - Phone:318-212-3636
Mailing Address - Fax:318-212-3649
Practice Address - Street 1:1811 E BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:SUITE 300
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5740
Practice Address - Country:US
Practice Address - Phone:318-212-3636
Practice Address - Fax:318-212-3649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1448222Medicaid
LA1448222Medicaid