Healthcare Provider Details

I. General information

NPI: 1144705930
Provider Name (Legal Business Name): DAVID RAINES COMMUNITY HEALTH CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2018
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 DAVID RAINES RD
SHREVEPORT LA
71107-5899
US

IV. Provider business mailing address

3041 DR MARTIN LUTHER KING DR
SHREVEPORT LA
71107-4705
US

V. Phone/Fax

Practice location:
  • Phone: 318-425-2252
  • Fax: 318-425-2367
Mailing address:
  • Phone: 318-227-3350
  • Fax: 318-222-2979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIE C WHITE III
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 318-227-3350