Provider Demographics
NPI:1821125261
Name:WESTSIDE RURAL HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:WESTSIDE RURAL HEALTH SERVICES, LLC
Other - Org Name:WESTSIDE RURAL HEALTH CLINIC OC PLAQUEMINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CYRIAC
Authorized Official - Middle Name:T
Authorized Official - Last Name:LUKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-687-0248
Mailing Address - Street 1:24730 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:PLAQUEMINE
Mailing Address - State:LA
Mailing Address - Zip Code:70764-6827
Mailing Address - Country:US
Mailing Address - Phone:225-687-0248
Mailing Address - Fax:225-687-8395
Practice Address - Street 1:24730 PLAZA DR
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764-6827
Practice Address - Country:US
Practice Address - Phone:225-687-0248
Practice Address - Fax:225-687-8395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04572R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1529460Medicaid
LA193868Medicare ID - Type UnspecifiedMEDICARE ID
LA1529460Medicaid