Provider Demographics
NPI:1073109930
Name:SOUTHSIDE FAMILY CLINIC LLC
Entity Type:Organization
Organization Name:SOUTHSIDE FAMILY CLINIC LLC
Other - Org Name:DELCAMBRE FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-580-4061
Mailing Address - Street 1:506 W HIGHWAY 14
Mailing Address - Street 2:
Mailing Address - City:DELCAMBRE
Mailing Address - State:LA
Mailing Address - Zip Code:70528-2308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:506 W HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:DELCAMBRE
Practice Address - State:LA
Practice Address - Zip Code:70528-2308
Practice Address - Country:US
Practice Address - Phone:337-685-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-15
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty