Provider Demographics
NPI:1851537930
Name:RURAL HEALTHCARE DEVELOPERS OF LOUISIANA LLC
Entity Type:Organization
Organization Name:RURAL HEALTHCARE DEVELOPERS OF LOUISIANA LLC
Other - Org Name:SOUTH CAMERON RURAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOEMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-321-1155
Mailing Address - Street 1:10080 GULF HWY
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-8672
Mailing Address - Country:US
Mailing Address - Phone:337-905-4111
Mailing Address - Fax:337-905-5711
Practice Address - Street 1:10080 GULF HWY
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-8672
Practice Address - Country:US
Practice Address - Phone:337-905-4111
Practice Address - Fax:337-905-5711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-19
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA534RHC-1261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1944335Medicaid
LA1944335Medicaid