Provider Demographics
NPI:1942500244
Name:DELTA GENETIC COUNSELING, LLC
Entity Type:Organization
Organization Name:DELTA GENETIC COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:S
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:318-278-1861
Mailing Address - Street 1:PO BOX 632
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71273-0632
Mailing Address - Country:US
Mailing Address - Phone:318-278-1861
Mailing Address - Fax:318-202-5193
Practice Address - Street 1:366 STOW CREEK RD
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-1643
Practice Address - Country:US
Practice Address - Phone:318-278-1861
Practice Address - Fax:318-202-5193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-02
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2133187Medicaid
LA2133187Medicaid