Provider Demographics
NPI:1205887981
Name:WK AND BONE & JOINT CLINIC - BOSSIER
Entity type:Organization
Organization Name:WK AND BONE & JOINT CLINIC - BOSSIER
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:318-212-8701
Mailing Address - Street 1:2449 HOSPITAL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2382
Mailing Address - Country:US
Mailing Address - Phone:318-425-8701
Mailing Address - Fax:318-424-0376
Practice Address - Street 1:2449 HOSPITAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2399
Practice Address - Country:US
Practice Address - Phone:318-425-8701
Practice Address - Fax:318-424-0376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA14924851Medicaid
614325700OtherUS DEPT OF LABOR
614325700OtherUS DEPT OF LABOR