1548538200 NPI number — LOUISIANA FAMILY MEDICINE CLINIC 1

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548538200 NPI number — LOUISIANA FAMILY MEDICINE CLINIC 1

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOUISIANA FAMILY MEDICINE CLINIC 1
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:
1548538200
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 WATTS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71251-2053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-259-1569
Provider Business Mailing Address Fax Number:
318-259-8523

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 WATTS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71251-2053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-259-1569
Provider Business Practice Location Address Fax Number:
318-259-8523
Provider Enumeration Date:
12/09/2011

Additional Information

Authorized Official

Authorized Official Last Name:
RAINWATER
Authorized Official First Name:
DIRK
Authorized Official Middle Name:
TIMOTHY
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
318-560-3486

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  025000 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QU0200X , with the licence number: 025000 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2344188 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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