Provider Demographics
NPI:1528133055
Name:J.K.S. PEDIATRICS, LLC
Entity type:Organization
Organization Name:J.K.S. PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:W
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-238-5040
Mailing Address - Street 1:740 KEYSER AVE
Mailing Address - Street 2:SUITE A-3
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-6037
Mailing Address - Country:US
Mailing Address - Phone:318-238-5040
Mailing Address - Fax:318-357-8842
Practice Address - Street 1:740 KEYSER AVE
Practice Address - Street 2:SUITE A-3
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-6037
Practice Address - Country:US
Practice Address - Phone:318-238-5040
Practice Address - Fax:318-357-8842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201180208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA05856513OtherECFMG
LA05856513OtherECFMG