Provider Demographics
NPI:1750311064
Name:OUTPATIENT MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:OUTPATIENT MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:ISIAH
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:318-357-2055
Mailing Address - Street 1:1640 BREAZEALE SPRINGS ST
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-4278
Mailing Address - Country:US
Mailing Address - Phone:318-352-9299
Mailing Address - Fax:318-352-0203
Practice Address - Street 1:804 N BEECH ST
Practice Address - Street 2:
Practice Address - City:TALLULAH
Practice Address - State:LA
Practice Address - Zip Code:71282
Practice Address - Country:US
Practice Address - Phone:318-574-1453
Practice Address - Fax:318-574-5876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1941042Medicaid
LA5D640Medicare ID - Type Unspecified
LA191804Medicare ID - Type Unspecified