Provider Demographics
NPI:1457330185
Name:GREEN CLINIC
Entity Type:Organization
Organization Name:GREEN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORA
Authorized Official - Middle Name:J
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-251-6216
Mailing Address - Street 1:1200 S FARMERVILLE ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5941
Mailing Address - Country:US
Mailing Address - Phone:318-251-6216
Mailing Address - Fax:
Practice Address - Street 1:1200 S FARMERVILLE ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5941
Practice Address - Country:US
Practice Address - Phone:318-251-6216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREEN CLINIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-11
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1542580Medicaid
LAC5055OtherBCBS LAB
LAC5055OtherBCBS LAB
LA=========AOtherBCBS LAB