1114256476 NPI number — WK SHREVEPORT CENTER FOR GERIATRIC HEALTH

Table of content: MRS. CALLANN LANE BOLINGER SUPERVISED MFT (NPI 1518711498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114256476 NPI number — WK SHREVEPORT CENTER FOR GERIATRIC HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WK SHREVEPORT CENTER FOR GERIATRIC HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114256476
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2508 BERT KOUNS LOOP
Provider Second Line Business Mailing Address:
SUITE 303
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71118-3133
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-212-5850
Provider Business Mailing Address Fax Number:
318-212-5855

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2508 BERT KOUNS LOOP
Provider Second Line Business Practice Location Address:
SUITE 303
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71118-3133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-212-5850
Provider Business Practice Location Address Fax Number:
318-212-5855
Provider Enumeration Date:
12/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GAVIN
Authorized Official First Name:
GREG
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
NETWORK ADMINISTRATOR
Authorized Official Telephone Number:
318-212-4232

Provider Taxonomy Codes

  • Taxonomy code: 2084P0805X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5DL73 . This is a "MEDICARE PTAN" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1818798 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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