MEDICARE: LOUISIANA FAMILY MEDICINE CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332900000X	Non-Pharmacy Dispensing Site

General Provider Information

NPI Number	:	1174903249
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOUISIANA FAMILY MEDICINE CLINIC

Provider Business Mailing Address
First Line	:	2890 DOUGLAS DR
Second Line	:	STE. 100
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-5806
Country	:	US
Telephone Number	:	318-742-6900
Fax Number	:	318-742-3900

Provider Business Practice Location Address
First Line	:	2890 DOUGLAS DR
Second Line	:	STE. 100
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-5806
Country	:	US
Telephone Number	:	318-742-6900
Fax Number	:	318-742-3900

Authorized Official
Title or Position	:	OWNER
Name	:	DIRK T. RAINWATER
Credential	:	MD
Telephone Number	:	318-259-1569

Provider Enumeration Date	:	06/04/2015
Last Update Date	:	06/04/2015

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