Provider Demographics
NPI:1295081909
Name:SWC RUSTON, LLC
Entity type:Organization
Organization Name:SWC RUSTON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:GOODYEAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-255-3223
Mailing Address - Street 1:1809 NORTHPOINTE LN
Mailing Address - Street 2:SUITE 103
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-3853
Mailing Address - Country:US
Mailing Address - Phone:318-255-3223
Mailing Address - Fax:318-255-3181
Practice Address - Street 1:1809 NORTHPOINTE LN
Practice Address - Street 2:SUITE 103
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3853
Practice Address - Country:US
Practice Address - Phone:318-255-3223
Practice Address - Fax:318-255-3181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.201086207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1453331Medicaid
1538166970OtherNPI
LAMD.201086OtherSTATE MEDICAL LICENSE