Provider Demographics
NPI:1174036388
Name:PINE PRAIRIE COMMUNITY CLINIC LLC
Entity Type:Organization
Organization Name:PINE PRAIRIE COMMUNITY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:ROLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:337-599-2800
Mailing Address - Street 1:PO BOX 542
Mailing Address - Street 2:
Mailing Address - City:PINE PRAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70576-0542
Mailing Address - Country:US
Mailing Address - Phone:337-599-2800
Mailing Address - Fax:337-599-2210
Practice Address - Street 1:1121 WALNUT STREET
Practice Address - Street 2:
Practice Address - City:PINE PRAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70576
Practice Address - Country:US
Practice Address - Phone:337-599-2800
Practice Address - Fax:337-599-2210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-09
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261Q00000X
LA2203783773261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center