Provider Demographics
NPI:1518570688
Name:DELTA MED CLINIC LLC
Entity Type:Organization
Organization Name:DELTA MED CLINIC LLC
Other - Org Name:DELTA MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBBIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:HAVARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-403-6085
Mailing Address - Street 1:1305 FOURTH ST
Mailing Address - Street 2:
Mailing Address - City:JONESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71343-2123
Mailing Address - Country:US
Mailing Address - Phone:318-403-6080
Mailing Address - Fax:318-403-6087
Practice Address - Street 1:1305 FOURTH ST STE A
Practice Address - Street 2:
Practice Address - City:JONESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71343-2123
Practice Address - Country:US
Practice Address - Phone:318-403-6053
Practice Address - Fax:318-403-6087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-28
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2346971Medicaid