Provider Demographics
NPI:1124149307
Name:ZWOLLE MEDICAL CLINIC
Entity type:Organization
Organization Name:ZWOLLE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARLAND
Authorized Official - Middle Name:DUPREE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MEDICAL DOCTOR
Authorized Official - Phone:318-645-4484
Mailing Address - Street 1:PO BOX 1068
Mailing Address - Street 2:
Mailing Address - City:ZWOLLE
Mailing Address - State:LA
Mailing Address - Zip Code:71486-1068
Mailing Address - Country:US
Mailing Address - Phone:318-645-4484
Mailing Address - Fax:318-645-9139
Practice Address - Street 1:2114 OBRIE STREET
Practice Address - Street 2:
Practice Address - City:ZWOLLE
Practice Address - State:LA
Practice Address - Zip Code:71486-1068
Practice Address - Country:US
Practice Address - Phone:318-645-4484
Practice Address - Fax:318-645-9139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16359261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1321702Medicaid
LA53083Medicare ID - Type Unspecified
LA1321702Medicaid