Provider Demographics
NPI:1760904981
Name:DAVID RAINES COMMUNITY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:DAVID RAINES COMMUNITY HEALTH CENTER, INC.
Other - Org Name:DAVID RAINES SCHOOL BASED HEALTH CENTER - LINWOOD
Other - Org Type:Doing Business As
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:CEO
Authorized Official - Phone:318-227-3350
Mailing Address - Street 1:3041 MARTIN LUTHER KING DRIVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-4705
Mailing Address - Country:US
Mailing Address - Phone:318-227-3350
Mailing Address - Fax:
Practice Address - Street 1:401 W 70TH ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-3034
Practice Address - Country:US
Practice Address - Phone:318-227-3350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-10
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)