Basic Information
| Provider Information | |||||||||
| NPI: | 1326093782 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILLIS KNIGHTON MEDICAL CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HOME HEALTH DEPARTMANT WILLIS KNIGHTON HOSPITAL INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32600 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711302600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182124544 | ||||||||
| FaxNumber: | 3182124192 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 ALBERT L BICKNELL DR | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711033903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182124180 | ||||||||
| FaxNumber: | 3182124382 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 12/05/2014 | ||||||||
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| AuthorizedOfficialLastName: | WARD | ||||||||
| AuthorizedOfficialFirstName: | MARY JANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIR DECISION SUPPORT | ||||||||
| AuthorizedOfficialTelephone: | 3182124384 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 65 | LA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 1400564 | 05 | LA | MEDICAID | 33562 | 01 | LA | BLUE CROSS/BLUE SHIELD | OTHER |