Provider Demographics
NPI:1053889261
Name:EAGLIN, KENNETH WAYNE JR
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
Last Name:EAGLIN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 YOUREE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-5117
Mailing Address - Country:US
Mailing Address - Phone:318-675-0804
Mailing Address - Fax:
Practice Address - Street 1:1017 SAINT JOHN ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501
Practice Address - Country:US
Practice Address - Phone:337-261-2300
Practice Address - Fax:337-261-9080
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator