Basic Information
| Provider Information | |||||||||
| NPI: | 1790390995 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WK PIERREMONT NEUROLOGY CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1202 LOUISIANA AVE | ||||||||
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| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711013910 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1811 E BERT KOUN LOOP STE 120 | ||||||||
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| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711055741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182122720 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2020 | ||||||||
| LastUpdateDate: | 09/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | WARD | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | JANE | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3182128299 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.