Healthcare Provider Details

I. General information

NPI: 1548538200
Provider Name (Legal Business Name): LOUISIANA FAMILY MEDICINE CLINIC 1
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2011
Last Update Date: 06/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 WATTS ST
JONESBORO LA
71251-2053
US

IV. Provider business mailing address

103 WATTS ST
JONESBORO LA
71251-2053
US

V. Phone/Fax

Practice location:
  • Phone: 318-259-1569
  • Fax: 318-259-8523
Mailing address:
  • Phone: 318-259-1569
  • Fax: 318-259-8523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number025000
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number025000
License Number StateLA

VIII. Authorized Official

Name: DIRK TIMOTHY RAINWATER
Title or Position: CEO
Credential: M.D.
Phone: 318-560-3486