Provider Demographics
NPI:1174903249
Name:LOUISIANA FAMILY MEDICINE CLINIC
Entity type:Organization
Organization Name:LOUISIANA FAMILY MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:T
Authorized Official - Last Name:RAINWATER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-259-1569
Mailing Address - Street 1:2890 DOUGLAS DR
Mailing Address - Street 2:STE. 100
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-5806
Mailing Address - Country:US
Mailing Address - Phone:318-742-6900
Mailing Address - Fax:318-742-3900
Practice Address - Street 1:2890 DOUGLAS DR
Practice Address - Street 2:STE. 100
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-5806
Practice Address - Country:US
Practice Address - Phone:318-742-6900
Practice Address - Fax:318-742-3900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-04
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site