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DSH190111H WILLIS KNIGHTON MEDICAL CENTER, INC. (Active)
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Main Details
Name
WILLIS KNIGHTON MEDICAL CENTER, INC.
Subdivision Name
O/PT RENAL DIAL
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH190111H
Medicare Provider Number
190111
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
4/12/2013
Participating Start Date
7/1/2013
Participating Approval Date
6/11/2013
Last Recertification Date
8/17/2024
Contacts
Authorizing Official
Willis-Knighton Medical Center
Mary Jane Ward, Senior Vice President - CFO
(318) 212-4384
Primary Contact
Willis-Knighton Medical Center
TESSA ALBRITTON, DIV. DIRECTOR OF PHARMACY
(318) 212-4039
Addresses
Street Address
1111 LINE AVE
SHREVEPORT, LA 71101
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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