Provider Demographics
NPI:1972532166
Name:WK SHREVEPORT BREAST CENTER
Entity type:Organization
Organization Name:WK SHREVEPORT BREAST 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 1:8001 YOUREE DR
Mailing Address - Street 2:SUITE 960
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-2302
Mailing Address - Country:US
Mailing Address - Phone:318-212-3706
Mailing Address - Fax:318-212-3708
Practice Address - Street 1:8001 YOUREE DR
Practice Address - Street 2:SUITE 960
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2302
Practice Address - Country:US
Practice Address - Phone:318-212-3706
Practice Address - Fax:318-212-3708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1447064Medicaid
LA1447064Medicaid