Provider Demographics
NPI:1386238525
Name:PROVIDENCE PRIMARY CARE, LLC
Entity type:Organization
Organization Name:PROVIDENCE PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDSEY
Authorized Official - Middle Name:MARLOWE
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:318-562-3911
Mailing Address - Street 1:1233 BIG PINE KEY LN
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-8728
Mailing Address - Country:US
Mailing Address - Phone:318-458-4526
Mailing Address - Fax:318-656-3761
Practice Address - Street 1:1000 CHINABERRY DR STE 1002
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2463
Practice Address - Country:US
Practice Address - Phone:318-562-3911
Practice Address - Fax:318-656-3761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-28
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty