Organization
WK PORTICO PEDIATRICS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GREG J. GAVIN (NETWORK ADMINISTRATOR)
(318) 212-4232
Entity
Organization
Contact information
Practice address
7847 YOUREE DR, SHREVEPORT, LA 71105-5505
(318) 212-3930
(318) 212-3935
Mailing address
7847 YOUREE DR, SHREVEPORT, LA 71105-5505
(318) 212-3930
(318) 212-3935
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
—
—
Other
Enumeration date
10/23/2009
Last updated
10/23/2009
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