Basic Information
| Provider Information | |||||||||
| NPI: | 1457664898 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WK AND THE ASTHMA-ALLERGY CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1202 LOUISIANA AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711013910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182128946 | ||||||||
| FaxNumber: | 3182124153 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 HOSPITAL DR | ||||||||
| Address2: | SUITE 345 | ||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711112394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182127780 | ||||||||
| FaxNumber: | 3182127785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2010 | ||||||||
| LastUpdateDate: | 07/21/2010 | ||||||||
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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 | 207KA0200X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy |
No ID Information.