Provider Demographics
NPI:1760042394
Name:DAVID RAINES COMMUNITY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:DAVID RAINES COMMUNITY HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:318-227-3350
Mailing Address - Street 1:3041 MARTIN LUTHER KING JR. DRIVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-5899
Mailing Address - Country:US
Mailing Address - Phone:318-227-3350
Mailing Address - Fax:318-222-2979
Practice Address - Street 1:4331 HENRY ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-6820
Practice Address - Country:US
Practice Address - Phone:318-635-2141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1941638Medicaid