Healthcare Provider Details

I. General information

NPI: 1346904885
Provider Name (Legal Business Name): CLHG-RUSTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2021
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E VAUGHN AVE STE 104
RUSTON LA
71270-5975
US

IV. Provider business mailing address

401 E VAUGHN AVE
RUSTON LA
71270-5950
US

V. Phone/Fax

Practice location:
  • Phone: 318-254-2100
  • Fax:
Mailing address:
  • Phone: 318-254-2453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: KATHY HALL
Title or Position: REGIONAL CLINIC OPERATIONS
Credential:
Phone: 318-254-2589