Healthcare Provider Details

I. General information

NPI: 1295081909
Provider Name (Legal Business Name): SWC RUSTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2012
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 NORTHPOINTE LN SUITE 103
RUSTON LA
71270-3853
US

IV. Provider business mailing address

1809 NORTHPOINTE LN SUITE 103
RUSTON LA
71270-3853
US

V. Phone/Fax

Practice location:
  • Phone: 318-255-3223
  • Fax: 318-255-3181
Mailing address:
  • Phone: 318-255-3223
  • Fax: 318-255-3181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberMD.201086
License Number StateLA

VIII. Authorized Official

Name: NATHAN WAYNE GOODYEAR
Title or Position: MEDICAL DOCTOR
Credential: M.D.
Phone: 318-255-3223