Provider Demographics
NPI:1104024686
Name:BOERSMA CLINIC, LLC
Entity Type:Organization
Organization Name:BOERSMA CLINIC, LLC
Other - Org Name:BOERSMA CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:STACK
Authorized Official - Last Name:BOERSMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-255-2733
Mailing Address - Street 1:765 S BONNER ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5801
Mailing Address - Country:US
Mailing Address - Phone:318-255-2733
Mailing Address - Fax:318-254-1066
Practice Address - Street 1:765 S BONNER ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5801
Practice Address - Country:US
Practice Address - Phone:318-255-2733
Practice Address - Fax:318-254-1066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTIN