Healthcare Provider Details

I. General information

NPI: 1063782811
Provider Name (Legal Business Name): RAYVILLE FAMILY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1962 JULIA ST
RAYVILLE LA
71269-5527
US

IV. Provider business mailing address

1962 JULIA ST
RAYVILLE LA
71269-5527
US

V. Phone/Fax

Practice location:
  • Phone: 318-728-8833
  • Fax: 318-728-6183
Mailing address:
  • Phone: 318-728-8833
  • Fax: 318-728-6183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number157
License Number StateLA

VIII. Authorized Official

Name: TRACY M MORRIS
Title or Position: ADMINISTRATOR
Credential:
Phone: 318-728-8833