Provider Demographics
NPI:1548538200
Name:LOUISIANA FAMILY MEDICINE CLINIC 1
Entity type:Organization
Organization Name:LOUISIANA FAMILY MEDICINE CLINIC 1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:RAINWATER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-560-3486
Mailing Address - Street 1:103 WATTS ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71251-2053
Mailing Address - Country:US
Mailing Address - Phone:318-259-1569
Mailing Address - Fax:318-259-8523
Practice Address - Street 1:103 WATTS ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:LA
Practice Address - Zip Code:71251-2053
Practice Address - Country:US
Practice Address - Phone:318-259-1569
Practice Address - Fax:318-259-8523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-09
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025000261QU0200X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2344188Medicaid
LA7323630001Medicare NSC
LA5DX99Medicare PIN