NPIMap

Organization Active NPI

David Raines Community Health Center, Inc

  • Federally Qualified Health Center (FQHC)
  • Shreveport, LA
National Provider Identifier
1144079872
Registry record updated May 15, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
DAVID RAINES COMMUNITY HEALTH CENTER, INC
Practice address
441 Atlantic Ave
Shreveport, LA 71105-2911
Phone
(318) 723-7242
NPI assigned
May 15, 2024
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 15, 2024

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

Authorized official

Name
Mr. Willie C White III
Title
Chief Executive Officer
Phone
(318) 723-7242

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

441 Atlantic Ave
Shreveport, LA 71105-2911

Mailing address

3041 Dr Martin Luther King Dr
Shreveport, LA 71107-4705
Phone (318) 723-7242

Other identifiers 1

IdentifierTypeStateIssuer
1941638MedicaidLA

Other names 1

  • David Raines School Based Health Center-Broadmoor Stem Academy Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20041007000508 LA Part B Supplier - Clinic/Group Practice 4688586118 Receives reassigned benefits from 67 practitioners
20 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Gilliam, LA; Shreveport, LA; Minden, LA; Keithville, LA; Hayneville, LA; Bossier City, LA
O20240828002361 LA Part A Provider - Federally Qualified Health Center (FQHC) 4688586118 Practice locations: Shreveport, LA

Federally qualified health center certification: CCN 191194

Legal name
DAVID RAINES COMMUNITY HEALTH CENTER, INC.
Doing business as
DAVID RAINES SBHC - BROADMOOR STEM ACADEMY
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 6, 2024
Last certification
Aug 6, 2024
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 20, 2024 in LA
Enrollment address
441 Atlantic Ave
Shreveport, LA 71105-2911

Other NPIs with the same Medicare PAC ID 17

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

View all 17

Other NPIs on the same Medicare enrollment 20

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

View all 20

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
19D2308004David Raines Community Health Centers - Broadmoor441 Atlantic Ave, Shreveport, LA 71105Certificate of waiverJul 17, 2028

National Provider Directory

National Provider Directory
Tax ID family
David Raines Community Health Center26 organizations share this tax ID, including this one

Other organizations with this tax ID 25

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

View all 25

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Darrell Webb Individual Corporate OfficerBoard Jan 1, 2026
Gladys Bush Individual Corporate OfficerTreasurer Jan 1, 2026
Deeandriez Wallace Individual Corporate Officer Mar 1, 2022
Stephen F Wright Individual Corporate Officer Mar 1, 2022
Fredrick Wilson Individual Corporate Officer Mar 1, 2022
Kenya Roberts Individual Corporate OfficerBoard Jan 1, 2026
Willie C White Individual Contracted Managing EmployeeCeo May 1, 1997
Corporate DirectorCeo May 1, 1997
Todd Hollenshead Individual Corporate Officer Mar 1, 2022
Myrtis Edwards Individual W-2 Managing EmployeeCoo Nov 6, 2001
Janice Sneed Individual Corporate OfficerBoard Jan 1, 2026
Ryan Williams Individual Corporate Officer Mar 1, 2022

NPI Registry JSON

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

{
    "created_epoch": "1715731200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1715731200000",
    "number": "1144079872",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3041 DR MARTIN LUTHER KING DR",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "711074705",
            "telephone_number": "318-723-7242",
            "fax_number": "318-222-2979"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "441 ATLANTIC AVE",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "711052911",
            "telephone_number": "318-723-7242"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DAVID RAINES COMMUNITY HEALTH CENTER, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-05-15",
        "last_updated": "2024-05-15",
        "certification_date": "2024-05-15",
        "status": "A",
        "authorized_official_last_name": "WHITE",
        "authorized_official_first_name": "WILLIE",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "318-723-7242",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "III"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1941638",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "David Raines School Based Health Center-Broadmoor Stem Academy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Shreveport, LA

Sources for this page

Verify at the official NPI Registry.