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General NPI Number Information
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NPI Number | 1295081909
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Entity Type | Organization
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Legal Business Name | SWC RUSTON, LLC
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Dates
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Enumeration Date | 07/31/2012
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Last Update Date | 07/31/2012
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Provider Practice Location Address
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Address Line | 1809 NORTHPOINTE LN SUITE 103
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City | RUSTON
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State | LA
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Zip | 71270-3853
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Country | US
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Telephone | 318-255-3223
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Fax | 318-255-3181
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Provider Business Mailing Address
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Address Line | 1809 NORTHPOINTE LN SUITE 103
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City | RUSTON
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State | LA
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Zip | 71270-3853
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Country | US
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Telephone | 318-255-3223
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Fax | 318-255-3181
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Authorized Official
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Title or Position | MEDICAL DOCTOR
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Name | NATHAN WAYNE GOODYEAR
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Credential | M.D.
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Telephone | 318-255-3223
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207VG0400X
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Taxonomy Name | Gynecology Physician
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License Number | MD.201086
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License Number State | LA
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