Organization
WK ARK-LA-TEX NEONATOLOGY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. GREG J GAVIN (NETWORK/ADMINISTRATOR)
(318) 212-4571
Entity
Organization
Contact information
Practice address
2510 BERT KOUNS LOOP, ROOM 215, SHREVEPORT, LA 71118-3119
(318) 212-5970
Mailing address
1202 LOUISIANA AVE, SHREVEPORT, LA 71101-3910
(318) 212-8946
Taxonomy
Speciality
Code
Description
License number
State
2080N0001X
Neonatal-Perinatal Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1816671
—
LA
Enumeration date
07/11/2008
Last updated
06/12/2012
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