Healthcare Provider Details

I. General information

NPI: 1912903964
Provider Name (Legal Business Name): DAVID RAINES COMMUNITY HEALTH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1953 MAIN ST
HAYNESVILLE LA
71038-4907
US

IV. Provider business mailing address

3041 DR MARTIN LUTHER KING DR
SHREVEPORT LA
71107-4705
US

V. Phone/Fax

Practice location:
  • Phone: 318-624-1995
  • Fax: 318-625-1985
Mailing address:
  • Phone: 318-227-3350
  • Fax: 318-222-2979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateLA

VIII. Authorized Official

Name: MR. WILLIE C WHITE III
Title or Position: CEO
Credential:
Phone: 318-425-2252