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General NPI Number Information
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NPI Number | 1578021093
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Entity Type | Organization
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Legal Business Name | GREEN CLINIC LLC
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Dates
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Enumeration Date | 03/04/2019
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Last Update Date | 03/04/2019
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Provider Practice Location Address
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Address Line | 1809 NORTHPOINTE LN STE 102
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City | RUSTON
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State | LA
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Zip | 71270-3852
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Country | US
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Telephone | 318-255-3762
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Fax |
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Provider Business Mailing Address
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Address Line | 1200 S FARMERVILLE ST
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City | RUSTON
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State | LA
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Zip | 71270-5941
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CFO
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Name | CHRISTOPHER ANDING STEGALL
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Credential |
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Telephone | 318-251-6304
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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