Basic Information
| Provider Information | |||||||||
| NPI: | 1144705930 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAVID RAINES COMMUNITY HEALTH CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3041 DR MARTIN LUTHER KING DR | ||||||||
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| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711074705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182273350 | ||||||||
| FaxNumber: | 3182222979 | ||||||||
| Practice Location | |||||||||
| Address1: | 1625 DAVID RAINES RD | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711075899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184252252 | ||||||||
| FaxNumber: | 3184252367 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2018 | ||||||||
| LastUpdateDate: | 09/27/2018 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | WILLIE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3182273350 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DAVID RAINES COMMUNITY HEALTH CENTER INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.