Provider Demographics
NPI:1366928277
Name:DRY PRONG FAMILY CLINIC, LLC
Entity type:Organization
Organization Name:DRY PRONG FAMILY CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLVIN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:318-568-8298
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:LA
Mailing Address - Zip Code:71454-0037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 GROVE STREET
Practice Address - Street 2:
Practice Address - City:DRY PRONG
Practice Address - State:LA
Practice Address - Zip Code:71423
Practice Address - Country:US
Practice Address - Phone:318-568-8298
Practice Address - Fax:318-568-8297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-13
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center