1174036388 NPI number — PINE PRAIRIE COMMUNITY CLINIC LLC

Table of content: (NPI 1174036388)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174036388 NPI number — PINE PRAIRIE COMMUNITY CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINE PRAIRIE COMMUNITY CLINIC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174036388
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 542
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINE PRAIRIE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70576-0542
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-599-2800
Provider Business Mailing Address Fax Number:
337-599-2210

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1121 WALNUT STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINE PRAIRIE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-599-2800
Provider Business Practice Location Address Fax Number:
337-599-2210
Provider Enumeration Date:
11/09/2017

Additional Information

Authorized Official

Authorized Official Last Name:
ROLLINS
Authorized Official First Name:
CARMEN
Authorized Official Middle Name:
NICOLE
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
337-599-2800

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X , with the licence number: 2203783773 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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