NPIMap

Organization Active NPI

David Raines Community Health Center, Inc

  • Federally Qualified Health Center (FQHC)
  • Shreveport, LA
National Provider Identifier
1215933254
Registry record updated Feb 13, 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
1625 David Raines Rd
Shreveport, LA 71107-5899
Phone
(318) 425-2252
Fax
(318) 716-3265
NPI assigned
Jun 23, 2005
Last updated
Feb 13, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 13, 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
Ceo
Phone
(318) 227-3350

Specialties & licenses 1

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

Addresses

Primary practice location

1625 David Raines Rd
Shreveport, LA 71107-5899

Mailing address

3041 Dr Martin Luther King Dr
Shreveport, LA 71107-4705
Phone (318) 227-3350

Other identifiers 1

IdentifierTypeStateIssuer
1941638MedicaidLA

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031104000096 LA Part A Provider - Federally Qualified Health Center (FQHC) 4688586118 Practice locations: Shreveport, LA
O20041007000508 LA Part B Supplier - Clinic/Group Practice 4688586118 Receives reassigned benefits from 67 practitioners
20 other NPIs on this enrollment
Practice locations: Gilliam, LA; Shreveport, LA; Minden, LA; Keithville, LA; Hayneville, LA; Bossier City, LA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1215933254. Details of each certification follow.

Federally qualified health center certification: CCN 191819

Legal name
DAVID RAINES COMMUNITY HEALTH CENTER, INC.
Doing business as
DAVID RAINES COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 1, 1992
Last certification
Sep 1, 1992
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 29, 1992 in LA
Enrollment address
1625 David Raines Rd
Shreveport, LA 71107-5899

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

National Provider Directory

National Provider Directory

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 OfficerBoard Mar 1, 2022
Stephen F Wright Individual Corporate OfficerPresident Mar 1, 2022
Fredrick Wilson Individual Corporate OfficerBoard Mar 1, 2022
Kenya Roberts Individual Corporate OfficerBoard Jan 1, 2026
Willie C White Individual Corporate DirectorCeo Dec 1, 2003
W-2 Managing EmployeeChief Executive Officer Jun 22, 2010
Todd Hollenshead Individual Corporate OfficerVice President Mar 1, 2022
Myrtis Edwards Individual W-2 Managing EmployeeChief Operating Officer Nov 2, 2001
Janice Sneed Individual Corporate OfficerBoard Jan 1, 2026
Ryan Williams Individual Corporate OfficerSecretary Mar 1, 2022

Practitioners & affiliated clinicians

Practitioners 67

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.

View all 67

NPI Registry JSON

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

{
    "created_epoch": "1119484800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1707782400000",
    "number": "1215933254",
    "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": "318-227-3350",
            "fax_number": "318-222-2979"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1625 DAVID RAINES RD",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "711075899",
            "telephone_number": "318-425-2252",
            "fax_number": "318-716-3265"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DAVID RAINES COMMUNITY HEALTH CENTER, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-06-23",
        "last_updated": "2024-02-13",
        "certification_date": "2024-02-13",
        "status": "A",
        "authorized_official_last_name": "WHITE",
        "authorized_official_first_name": "WILLIE",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "318-227-3350",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "III"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "LA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1941638",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Shreveport, LA

Sources for this page

Verify at the official NPI Registry.