Provider Demographics
NPI:1609066646
Name:HOMER MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:HOMER MEMORIAL HOSPITAL
Other - Org Name:CLAIBORNE MEMORIAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:RHIA
Authorized Official - Phone:318-927-2024
Mailing Address - Street 1:PO BOX 809
Mailing Address - Street 2:620 E COLLEGE ST.
Mailing Address - City:HOMER
Mailing Address - State:LA
Mailing Address - Zip Code:71040
Mailing Address - Country:US
Mailing Address - Phone:318-927-2024
Mailing Address - Fax:318-972-9212
Practice Address - Street 1:620 EAST COLLEGE ST.
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:LA
Practice Address - Zip Code:71040
Practice Address - Country:US
Practice Address - Phone:318-927-2024
Practice Address - Fax:318-927-9212
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOMER MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-26
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA206207P00000X, 367500000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1705802Medicaid
LA04802OtherBLUE CROSS
LA1799645Medicaid
LA1705802Medicaid
LA1799645Medicaid