Provider Demographics
NPI:1770936965
Name:LA PORTE CLINIC COMPANY LLC
Entity type:Organization
Organization Name:LA PORTE CLINIC COMPANY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR DIRECTOR PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:615-778-8071
Mailing Address - Fax:
Practice Address - Street 1:104 E CULVER RD
Practice Address - Street 2:SUITE 102
Practice Address - City:KNOX
Practice Address - State:IN
Practice Address - Zip Code:46534-2241
Practice Address - Country:US
Practice Address - Phone:219-326-2461
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-22
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health