Provider Demographics
NPI:1144267451
Name:WILLIS KNIGHTON MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:WILLIS KNIGHTON MEDICAL CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:H
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-4877
Mailing Address - Street 1:PO BOX 32600
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71130-2600
Mailing Address - Country:US
Mailing Address - Phone:318-212-8200
Mailing Address - Fax:318-212-8220
Practice Address - Street 1:2550 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3922
Practice Address - Country:US
Practice Address - Phone:318-212-8200
Practice Address - Fax:318-212-8220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA232314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA195622Medicare ID - Type Unspecified