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DSH190111R WILLIS KNIGHTON MEDICAL CENTER, INC. (Active)
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Main Details
Name
WILLIS KNIGHTON MEDICAL CENTER, INC.
Subdivision Name
PORTICO IMAGING
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH190111R
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
7925 YOUREE DR
SHREVEPORT, LA 71105
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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