Provider Demographics
NPI:1861581092
Name:GREEN CLINIC SURGICAL CENTER
Entity type:Organization
Organization Name:GREEN CLINIC SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-232-7186
Mailing Address - Street 1:PO BOX 1586
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71273-1586
Mailing Address - Country:US
Mailing Address - Phone:318-232-7148
Mailing Address - Fax:318-232-1092
Practice Address - Street 1:1200 S FARMERVILLE ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5941
Practice Address - Country:US
Practice Address - Phone:318-232-7148
Practice Address - Fax:318-232-1092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA87261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA20063OtherBCBS PROVIDER NO.
LA1563951Medicaid
LA20063OtherBCBS PROVIDER NO.