Provider Demographics
NPI:1720620784
Name:WK CENTER FOR PEDIATRIC GASTROENTEROLOGY
Entity Type:Organization
Organization Name:WK CENTER FOR PEDIATRIC GASTROENTEROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MARY JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-8951
Mailing Address - Street 1:WK CENTER FOR PEDIATRIC GASTROENTEROLOGY
Mailing Address - Street 2:2530 BERT KOUNS INDUSTRIAL LOOP, STE 113
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118
Mailing Address - Country:US
Mailing Address - Phone:318-212-5811
Mailing Address - Fax:318-212-5844
Practice Address - Street 1:WK CENTER FOR PEDIATRIC GASTROENTEROLOGY
Practice Address - Street 2:2530 BERT KOUNS INDUSTRIAL LOOP, STE 113
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118
Practice Address - Country:US
Practice Address - Phone:318-212-5811
Practice Address - Fax:318-212-5844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Single Specialty