Provider Demographics
NPI:1063782811
Name:RAYVILLE FAMILY CLINIC
Entity type:Organization
Organization Name:RAYVILLE FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-728-8833
Mailing Address - Street 1:1962 JULIA ST
Mailing Address - Street 2:
Mailing Address - City:RAYVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71269-5527
Mailing Address - Country:US
Mailing Address - Phone:318-728-8833
Mailing Address - Fax:318-728-6183
Practice Address - Street 1:1962 JULIA ST
Practice Address - Street 2:
Practice Address - City:RAYVILLE
Practice Address - State:LA
Practice Address - Zip Code:71269-5527
Practice Address - Country:US
Practice Address - Phone:318-728-8833
Practice Address - Fax:318-728-6183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA157261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2168339Medicaid