NPIMap

Organization Active NPI

Southside Family Clinic LLC

Doing business as Delcambre Family Clinic

  • Rural Health Clinic/Center
  • Delcambre, LA
National Provider Identifier
1073109930
Registry record updated Mar 14, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
SOUTHSIDE FAMILY CLINIC LLC
Doing business as
Delcambre Family Clinic
Practice address
506 W Highway 14
Delcambre, LA 70528-2308
Phone
(337) 685-2020
NPI assigned
Dec 15, 2020
Last updated
Mar 14, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 14, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
John DiesNPI 1477971083
Title
President
Phone
(337) 580-4061

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary
Family Nurse Practitioner 363LF0000X

Addresses

Primary practice location

506 W Highway 14
Delcambre, LA 70528-2308

Mailing address

506 W Highway 14
Delcambre, LA 70528-2308

Other names 1

  • Delcambre Family Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in LA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20171107000495 LA Part B Supplier - Clinic/Group Practice 3779859392 Receives reassigned benefits from 6 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Abbeville, LA; Delcambre, LA; Arnaudville, LA
O20210624002988 LA Part A Provider - Rural Health Clinic 3779859392 Practice locations: Delcambre, LA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1073109930. Details of each certification follow.

Rural health clinic certification: CCN 198904

Legal name
SOUTHSIDE FAMILY CLINIC LLC
Doing business as
DELCAMBRE FAMILY CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Nov 16, 2021
Last certification
Nov 16, 2021
Ownership / control type
1B
Organization structure
LLCProprietary
Incorporated
May 25, 2017 in LA
Enrollment address
506 W Highway 14
Delcambre, LA 70528-2308

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Arnaudville Family Clinic3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Locations

304 N Hospital Dr
#A
Abbeville, LA 70510
Phone (337) 385-1972

506 W Highway 14
Delcambre, LA 70528
Phone (337) 385-1972

Ownership & related parties

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Joseph Heinen Individual 5% Or Greater Direct Ownership InterestPresident Jul 28, 2017 50%
General Partnership InterestPresident Jul 28, 2017 50%
Corporate OfficerPresident Jul 28, 2017 5%
Operational/Managerial ControlPresident Jul 28, 2017 50%
John P Dies Individual 5% Or Greater Direct Ownership InterestPresident Jul 28, 2017 50%
General Partnership InterestPresident Jul 28, 2017 50%
Corporate OfficerPresident Jul 28, 2017 50%
Operational/Managerial ControlPresident Jul 28, 2017 50%

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

  • John Dies, N.P.
    • Family Nurse Practitioner
    • Abbeville, LA
    • NPI 1477971083

    5% Or Greater Direct Ownership Interest, Corporate Officer, General Partnership Interest, Operational/Managerial Control

    CMS ownership
  • Joseph Nicholas Heinen Sr., M.D.
    • Family Medicine Physician
    • Eunice, LA
    • NPI 1316188386

    5% Or Greater Direct Ownership Interest, Corporate Officer, General Partnership Interest, Operational/Managerial Control

    CMS ownership

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1607990400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1647216000000",
    "number": "1073109930",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "506 W HIGHWAY 14",
            "city": "DELCAMBRE",
            "state": "LA",
            "postal_code": "705282308"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "506 W HIGHWAY 14",
            "city": "DELCAMBRE",
            "state": "LA",
            "postal_code": "705282308",
            "telephone_number": "337-685-2020"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHSIDE FAMILY CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-12-15",
        "last_updated": "2022-03-14",
        "certification_date": "2022-03-14",
        "status": "A",
        "authorized_official_last_name": "DIES",
        "authorized_official_first_name": "JOHN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "337-580-4061"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Delcambre Family Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Delcambre Family Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Delcambre, LA

Sources for this page

Verify at the official NPI Registry.