Healthcare Provider Details

I. General information

NPI: 1104024686
Provider Name (Legal Business Name): BOERSMA CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 S BONNER ST
RUSTON LA
71270-5801
US

IV. Provider business mailing address

765 S BONNER ST
RUSTON LA
71270-5801
US

V. Phone/Fax

Practice location:
  • Phone: 318-255-2733
  • Fax: 318-254-1066
Mailing address:
  • Phone: 318-255-2733
  • Fax: 318-254-1066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. RACHEL STACK BOERSMA
Title or Position: OWNER
Credential:
Phone: 318-255-2733