Provider Demographics
NPI:1063769255
Name:WK TOTS TO TEENS PEDIATRIC CENTER
Entity type:Organization
Organization Name:WK TOTS TO TEENS PEDIATRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NETWORK ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-4232
Mailing Address - Street 1:845 OLIVE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2141
Mailing Address - Country:US
Mailing Address - Phone:318-226-4892
Mailing Address - Fax:318-227-4927
Practice Address - Street 1:845 OLIVE ST
Practice Address - Street 2:SUITE A
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2141
Practice Address - Country:US
Practice Address - Phone:318-226-4892
Practice Address - Fax:318-227-4927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty