Active NPI
Allegiance Medical Clinic of Dequincy LLC
- Rural Health Clinic/Center
- Dequincy, LA
National Provider Identifier
1073267076
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Rural Health Clinic/Center
- Legal business name
- ALLEGIANCE MEDICAL CLINIC OF DEQUINCY LLC
- Practice address
- 601 W 4TH St
Dequincy, LA 70633-3301 - Phone
- (337) 786-6161
- Fax
- (337) 786-7999
- NPI assigned
- Feb 8, 2022
- Last updated
- Sep 19, 2024
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Renee Michelle Willis
- Title
- Clinic Manager
- Phone
- (337) 786-1271
Specialties & licenses 7
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Multi-Specialty Clinic/Center | 261QM1300X | |||
| Rural Health Clinic/Center | 261QR1300X | Primary | ||
| Pediatric Nurse Practitioner | 363LP0200X | |||
| Family Medicine Physician | 207Q00000X | |||
| Internal Medicine Physician | 207R00000X | |||
| Pediatrics Physician | 208000000X | |||
| Podiatrist | 213E00000X |
Addresses
Primary practice location
601 W 4TH St
Dequincy, LA 70633-3301
Mailing address
601 W 4TH St
Dequincy, LA 70633-3301
Phone (337) 786-6161
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in LA
Enrollment records 2
NPI to CCN mapping 1
The Medicare certification numbers (CCNs) connected to NPI 1073267076. Details of each certification follow.
Rural health clinic certification: CCN 198925
- Legal name
- ALLEGIANCE MEDICAL CLINIC OF DEQUINCY LLC
- Doing business as
- ALLEGIANCE MEDICAL CLINIC OF DEQUINCY
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Mar 18, 2024
- Last certification
- Mar 18, 2024
- Ownership / control type
- 1B
- Organization structure
- LLC
- Enrollment address
- 601 W 4TH St
Dequincy, LA 70633-3301
National Provider Directory
National Provider Directory- Tax ID family
- Allegiance Medical Clinic of Dequincy
Other organizations with this tax ID 1
Organizations that report the same tax identification number in the National Provider Directory.
-
- Rural Health Clinic/Center
- Dequincy, LA
- NPI 1760136766
Locations
601 W 4th St
Dequincy, LA 70633
Phone (337) 786-6161
Ownership & related parties
All disclosed owners & managing parties 1
As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.
| Name | Role | Since | Share |
|---|---|---|---|
| Rock Bordelon | 5% Or Greater Direct Ownership Interest | Sep 1, 2022 | 100% |
| Corporate Officer | Sep 1, 2022 | 100% | |
| Operational/Managerial Control | Sep 1, 2022 | 100% |
Practitioners & affiliated clinicians
Practitioners 6
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.
-
- Nurse Practitioner
- Lake Charles, LA
- NPI 1396513610
-
- Internal Medicine Physician
- Dequincy, LA
- NPI 1861425324
-
- Podiatrist
- Leesville, LA
- NPI 1518526334
-
- Family Medicine Physician
- Lake Charles, LA
- NPI 1346701422
-
- Family Nurse Practitioner
- Monroe, LA
- NPI 1285996306
-
- Family Nurse Practitioner
- Deridder, LA
- NPI 1194334433
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1644278400000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1726704000000",
"number": "1073267076",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "601 W 4TH ST",
"city": "DEQUINCY",
"state": "LA",
"postal_code": "706333301",
"telephone_number": "337-786-6161",
"fax_number": "337-786-7999"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "601 W 4TH ST",
"city": "DEQUINCY",
"state": "LA",
"postal_code": "706333301",
"telephone_number": "337-786-6161",
"fax_number": "337-786-7999"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "ALLEGIANCE MEDICAL CLINIC OF DEQUINCY LLC",
"organizational_subpart": "NO",
"enumeration_date": "2022-02-08",
"last_updated": "2024-09-19",
"certification_date": "2024-09-19",
"status": "A",
"authorized_official_last_name": "WILLIS",
"authorized_official_first_name": "RENEE",
"authorized_official_middle_name": "MICHELLE",
"authorized_official_title_or_position": "CLINIC MANAGER",
"authorized_official_telephone_number": "337-786-1271"
},
"taxonomies": [
{
"code": "261QM1300X",
"taxonomy_group": "",
"desc": "Clinic/Center, Multi-Specialty",
"state": null,
"license": null,
"primary": false
},
{
"code": "261QR1300X",
"taxonomy_group": "",
"desc": "Clinic/Center, Rural Health",
"state": null,
"license": null,
"primary": true
},
{
"code": "363LP0200X",
"taxonomy_group": "",
"desc": "Nurse Practitioner, Pediatrics",
"state": null,
"license": null,
"primary": false
},
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": null,
"license": null,
"primary": false
},
{
"code": "207R00000X",
"taxonomy_group": "",
"desc": "Internal Medicine",
"state": null,
"license": null,
"primary": false
},
{
"code": "208000000X",
"taxonomy_group": "",
"desc": "Pediatrics",
"state": null,
"license": null,
"primary": false
},
{
"code": "213E00000X",
"taxonomy_group": "",
"desc": "Podiatrist",
"state": null,
"license": null,
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Dequincy, LA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 19, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.