Provider Demographics
NPI:1811381072
Name:CHENEVERT FAMILY CARE CLINIC, LLC
Entity Type:Organization
Organization Name:CHENEVERT FAMILY CARE CLINIC, LLC
Other - Org Name:CHENEVERT FAMILY CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORA
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHENEVERT
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:318-279-2300
Mailing Address - Street 1:PO BOX 385
Mailing Address - Street 2:
Mailing Address - City:CHENEYVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71325-0385
Mailing Address - Country:US
Mailing Address - Phone:318-279-2300
Mailing Address - Fax:318-279-2302
Practice Address - Street 1:501 FRONT ST
Practice Address - Street 2:
Practice Address - City:CHENEYVILLE
Practice Address - State:LA
Practice Address - Zip Code:71325-0385
Practice Address - Country:US
Practice Address - Phone:318-279-2300
Practice Address - Fax:318-279-2302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-26
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07392261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2338773Medicaid