Provider Demographics
NPI:1376630632
Name:DAVID RAINES COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:DAVID RAINES COMMUNITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:318-425-2252
Mailing Address - Street 1:1625 DAVID RAINES RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-5899
Mailing Address - Country:US
Mailing Address - Phone:318-425-2252
Mailing Address - Fax:318-227-8510
Practice Address - Street 1:1625 DAVID RAINES RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-5899
Practice Address - Country:US
Practice Address - Phone:318-425-2252
Practice Address - Fax:318-227-8510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA=========OtherEIN