Basic Information
| Provider Information | |||||||||
| NPI: | 1063769255 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WK TOTS TO TEENS PEDIATRIC CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 845 OLIVE ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711042141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182264892 | ||||||||
| FaxNumber: | 3182274927 | ||||||||
| Practice Location | |||||||||
| Address1: | 845 OLIVE ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711042141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182264892 | ||||||||
| FaxNumber: | 3182274927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2012 | ||||||||
| LastUpdateDate: | 08/07/2012 | ||||||||
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| AuthorizedOfficialLastName: | GAVIN | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | NETWORK ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3182124232 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.