Provider Demographics
NPI:1992731301
Name:WILLIS KNIGHTON MEDICAL CENTER & M R MANCHANDIA
Entity type:Organization
Organization Name:WILLIS KNIGHTON MEDICAL CENTER & M R MANCHANDIA
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:318-747-5272
Mailing Address - Street 1:2706 SHED RD
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3348
Mailing Address - Country:US
Mailing Address - Phone:318-747-5272
Mailing Address - Fax:318-746-9669
Practice Address - Street 1:2706 SHED RD
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3348
Practice Address - Country:US
Practice Address - Phone:318-747-5272
Practice Address - Fax:318-746-9669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty