Provider Demographics
NPI:1982017273
Name:FAMILY HEALTHCARE OF BEAUREGARD, L.L.C.
Entity Type:Organization
Organization Name:FAMILY HEALTHCARE OF BEAUREGARD, L.L.C.
Other - Org Name:EDWIN R. BONILLA, M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:L
Authorized Official - Last Name:KINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:337-462-7111
Mailing Address - Street 1:PO BOX 935
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-0935
Mailing Address - Country:US
Mailing Address - Phone:337-463-8977
Mailing Address - Fax:337-462-3093
Practice Address - Street 1:403 W 8TH ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-5507
Practice Address - Country:US
Practice Address - Phone:337-463-8977
Practice Address - Fax:337-462-3093
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST LOUISIANA HEALTH SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care