Provider Demographics
NPI:1962673459
Name:OUR CLINIC, INC
Entity Type:Organization
Organization Name:OUR CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-451-5320
Mailing Address - Street 1:40189 PELICAN POINT PKWY
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-8501
Mailing Address - Country:US
Mailing Address - Phone:504-491-3124
Mailing Address - Fax:
Practice Address - Street 1:4301 ELYSIAN FIELDS AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70122-3875
Practice Address - Country:US
Practice Address - Phone:504-284-3866
Practice Address - Fax:504-284-3869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.06513R207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1344681Medicaid