MEDICARE: DAVID RAINES COMMUNITY HEALTH CENTER, INC.

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	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487178315
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVID RAINES COMMUNITY HEALTH CENTER, INC.

Provider Business Mailing Address
First Line	:	3041 MARTIN LUTHER KING DRIVE
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71107-4705
Country	:	US
Telephone Number	:	318-227-3350
Fax Number	:

Provider Business Practice Location Address
First Line	:	7611 SAINT VINCENT AVE
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71106-4231
Country	:	US
Telephone Number	:	318-868-2810
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. WILLIE C. WHITE III
Credential	:	CEO
Telephone Number	:	318-227-3350

Provider Enumeration Date	:	08/02/2017
Last Update Date	:	08/02/2017

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