Healthcare Provider Details

I. General information

NPI: 1366928277
Provider Name (Legal Business Name): DRY PRONG FAMILY CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2018
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 GROVE STREET
DRY PRONG LA
71423
US

IV. Provider business mailing address

PO BOX 37
MONTGOMERY LA
71454-0037
US

V. Phone/Fax

Practice location:
  • Phone: 318-568-8298
  • Fax: 318-568-8297
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN COLVIN
Title or Position: OWNER
Credential: FNP
Phone: 318-568-8298