Organization
WK KINNEBREW AND JOHNSON CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GREG J. GAVIN (NETWORK ADMINISTRATOR)
(318) 212-4232
Entity
Organization
Contact information
Practice address
2508 BERT KOUNS LOOP STE 102, SHREVEPORT, LA 71118-3175
(318) 688-6630
(318) 688-6014
Mailing address
2508 BERT KOUNS LOOP STE 102, SHREVEPORT, LA 71118-3175
(318) 688-6630
(318) 688-6014
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1021652
—
LA
Enumeration date
10/24/2007
Last updated
06/08/2012
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