Basic Information
Provider Information | |||||||||
NPI: | 1346567831 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | C. H. WILKINSON PHYSICIAN NETWORK | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE CLINIC AT WALMART, STORE #75 | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1700 WEST LOOP S | ||||||||
Address2: | SUITE 400B | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770273005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7132272222 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3636 MONROE HWY | ||||||||
Address2: |   | ||||||||
City: | PINEVILLE | ||||||||
State: | LA | ||||||||
PostalCode: | 713604127 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3186413137 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2010 | ||||||||
LastUpdateDate: | 04/23/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MIKULECKY | ||||||||
AuthorizedOfficialFirstName: | DONNA | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | CEO PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7132772202 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 1445266 | 05 | LA |   | MEDICAID |