Basic Information
| Provider Information | |||||||||
| NPI: | 1912939687 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WK PLAIN DEALING MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3038 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711333038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182128946 | ||||||||
| FaxNumber: | 3182124025 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 N LOUISIANA ST | ||||||||
| Address2: | |||||||||
| City: | PLAIN DEALING | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710643446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183267272 | ||||||||
| FaxNumber: | 3183267282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 01/02/2009 | ||||||||
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| AuthorizedOfficialLastName: | GAVIN | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | NETWORK ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3183267272 | ||||||||
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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 | 1948306 | 05 | LA | MEDICAID |