Provider Demographics
NPI:1821106444
Name:NORTHEAST RURAL HEALTH CENTER
Entity Type:Organization
Organization Name:NORTHEAST RURAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:TENNANT
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:318-387-4878
Mailing Address - Street 1:PO BOX 2141
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71207-0000
Mailing Address - Country:US
Mailing Address - Phone:318-387-4878
Mailing Address - Fax:318-387-1317
Practice Address - Street 1:1108 STUBBS AVENUE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71207
Practice Address - Country:US
Practice Address - Phone:318-387-4878
Practice Address - Fax:318-387-1317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1947695Medicaid
LA1947695Medicaid