Provider Demographics
NPI:1336292432
Name:RUSTON CLINIC COMPANY LLC
Entity Type:Organization
Organization Name:RUSTON CLINIC COMPANY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHYSICIAN OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SOPHIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ARWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-628-6038
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:615-628-6038
Mailing Address - Fax:615-628-6832
Practice Address - Street 1:401 E VAUGHN AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5950
Practice Address - Country:US
Practice Address - Phone:318-254-7590
Practice Address - Fax:318-254-2229
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RUSTON CLINIC COMPANY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-19
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1449202Medicaid
LA5CX79Medicare PIN