Basic Information
| Provider Information | |||||||||
| NPI: | 1407888209 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WK BUTLER-ABSHIRE MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 271 | ||||||||
| Address2: | |||||||||
| City: | HAYNESVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710380271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186240554 | ||||||||
| FaxNumber: | 3186243782 | ||||||||
| Practice Location | |||||||||
| Address1: | 926 FRANCES DR | ||||||||
| Address2: | |||||||||
| City: | HAYNESVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710386100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186240554 | ||||||||
| FaxNumber: | 3186243782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 08/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | GAVIN | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | NETWORK ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3186240554 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 1944327 | 05 | LA | MEDICAID | 136859729 | 05 | AK | MEDICAID |