Provider Demographics
NPI:1164112074
Name:SOUTHSIDE FAMILY CLINIC LLC
Entity Type:Organization
Organization Name:SOUTHSIDE FAMILY CLINIC LLC
Other - Org Name:
Other - Org Type:
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 1:304 N HOSPITAL DR STE A
Mailing Address - Street 2:
Mailing Address - City:ABBEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70510-4041
Mailing Address - Country:US
Mailing Address - Phone:337-385-1972
Mailing Address - Fax:337-385-2849
Practice Address - Street 1:119 FUSELIER RD
Practice Address - Street 2:
Practice Address - City:ARNAUDVILLE
Practice Address - State:LA
Practice Address - Zip Code:70512-6134
Practice Address - Country:US
Practice Address - Phone:337-385-1972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health