Provider Demographics
NPI:1609825892
Name:COUNTRY CLINIC, LLC
Entity Type:Organization
Organization Name:COUNTRY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUPLESKY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:318-941-2057
Mailing Address - Street 1:PO BOX 80735
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70598-0735
Mailing Address - Country:US
Mailing Address - Phone:800-564-8971
Mailing Address - Fax:866-693-1704
Practice Address - Street 1:314 CHRISTINE LN
Practice Address - Street 2:
Practice Address - City:SIMMESPORT
Practice Address - State:LA
Practice Address - Zip Code:71369-2256
Practice Address - Country:US
Practice Address - Phone:318-941-2057
Practice Address - Fax:318-941-2067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1445665Medicaid