Provider Demographics
NPI:1861415721
Name:DAVID RAINES COMMUNITY HEALTH CENTER INC
Entity type:Organization
Organization Name:DAVID RAINES COMMUNITY HEALTH CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-227-3342
Mailing Address - Street 1:1625 DAVID RAINES RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-5899
Mailing Address - Country:US
Mailing Address - Phone:318-227-3355
Mailing Address - Fax:318-227-3356
Practice Address - Street 1:1625 DAVID RAINES RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-5899
Practice Address - Country:US
Practice Address - Phone:318-227-3355
Practice Address - Fax:318-227-3356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X, 3336M0003X, 333600000X
LAPHY.005457-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1233358Medicaid
2035347OtherPK