Provider Demographics
NPI:1063642114
Name:DAVENPORT FAMILY MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:DAVENPORT FAMILY MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PEARRE
Authorized Official - Middle Name:JONES
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:337-460-0690
Mailing Address - Street 1:101 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-4963
Mailing Address - Country:US
Mailing Address - Phone:337-460-0690
Mailing Address - Fax:
Practice Address - Street 1:101 W 6TH ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-4963
Practice Address - Country:US
Practice Address - Phone:337-460-0690
Practice Address - Fax:337-460-0961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care