Provider Demographics
NPI:1902085186
Name:WK KINNEBREW AND JOHNSON CLINIC
Entity Type:Organization
Organization Name:WK KINNEBREW AND JOHNSON CLINIC
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:318-212-4232
Mailing Address - Street 1:2508 BERT KOUNS LOOP STE 102
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3175
Mailing Address - Country:US
Mailing Address - Phone:318-688-6630
Mailing Address - Fax:318-688-6014
Practice Address - Street 1:2508 BERT KOUNS LOOP STE 102
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3175
Practice Address - Country:US
Practice Address - Phone:318-688-6630
Practice Address - Fax:318-688-6014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1021652Medicaid
LA1021652Medicaid