MEDICARE: LOUISIANA FAMILY MEDICINE CLINIC 1

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QU0200X	Urgent Care Clinic/Center	025000	LA
2	261Q00000X	Clinic/Center	025000	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548538200
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOUISIANA FAMILY MEDICINE CLINIC 1

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

Provider Business Practice Location Address
First Line	:	103 WATTS ST
Second Line	:
City	:	JONESBORO
State	:	LA
Zip	:	71251-2053
Country	:	US
Telephone Number	:	318-259-1569
Fax Number	:	318-259-8523

Authorized Official
Title or Position	:	CEO
Name	:	DIRK TIMOTHY RAINWATER
Credential	:	M.D.
Telephone Number	:	318-560-3486

Provider Enumeration Date	:	12/09/2011
Last Update Date	:	06/18/2015

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