Provider Demographics
NPI:1598181869
Name:CLAIBORNE, RITA S (OWNER)
Entity type:Individual
Prefix:
First Name:RITA
Middle Name:S
Last Name:CLAIBORNE
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 S GONZALES TRACE AVE
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-1605
Mailing Address - Country:US
Mailing Address - Phone:225-227-0973
Mailing Address - Fax:225-264-6408
Practice Address - Street 1:1523 S GONZALES TRACE AVE
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-1605
Practice Address - Country:US
Practice Address - Phone:225-227-0973
Practice Address - Fax:225-264-6408
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-11
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAM3458343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA46-4170007Medicaid