Provider Demographics
NPI:1073267076
Name:ALLEGIANCE MEDICAL CLINIC OF DEQUINCY LLC
Entity type:Organization
Organization Name:ALLEGIANCE MEDICAL CLINIC OF DEQUINCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-786-1271
Mailing Address - Street 1:601 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DEQUINCY
Mailing Address - State:LA
Mailing Address - Zip Code:70633-3301
Mailing Address - Country:US
Mailing Address - Phone:337-786-6161
Mailing Address - Fax:337-786-7999
Practice Address - Street 1:601 W 4TH ST
Practice Address - Street 2:
Practice Address - City:DEQUINCY
Practice Address - State:LA
Practice Address - Zip Code:70633-3301
Practice Address - Country:US
Practice Address - Phone:337-786-6161
Practice Address - Fax:337-786-7999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-08
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty