Provider Demographics
NPI:1831438027
Name:WK EYE CENTER AT TOWNE OAKS
Entity type:Organization
Organization Name:WK EYE CENTER AT TOWNE OAKS
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:318-212-8780
Mailing Address - Street 1:855 PIERREMONT RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-2040
Mailing Address - Country:US
Mailing Address - Phone:318-213-3333
Mailing Address - Fax:318-213-3332
Practice Address - Street 1:855 PIERREMONT RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-2040
Practice Address - Country:US
Practice Address - Phone:318-213-3333
Practice Address - Fax:318-213-3332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-07
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA275381OtherMEDICARE PTAN