Healthcare Provider Details

I. General information

NPI: 1285664508
Provider Name (Legal Business Name): OUTPATIENT MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 S 10TH ST STE B
LEESVILLE LA
71446
US

IV. Provider business mailing address

1640 BREAZEALE SPRINGS ST
NATCHITOCHES LA
71457-4278
US

V. Phone/Fax

Practice location:
  • Phone: 337-238-1274
  • Fax: 337-239-2225
Mailing address:
  • Phone: 318-352-9299
  • Fax: 318-352-0203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: CARL ISIAH WALTERS
Title or Position: CEO
Credential:
Phone: 318-357-2055