NPIMap

Organization Active NPI

Outpatient Medical Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Leesville, LA
National Provider Identifier
1285664508
Registry record updated Aug 29, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
OUTPATIENT MEDICAL CENTER, INC.
Practice address
908 S 10TH St Ste B
Leesville, LA 71446
Phone
(337) 238-1274
Fax
(337) 239-2225
NPI assigned
Jul 3, 2006
Last updated
Aug 29, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 29, 2018

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

Authorized official

Name
Carl Isiah Walters
Title
Ceo
Phone
(318) 357-2055

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
DentistGroup: 193200000X MULTI-SPECIALTY GROUP 122300000X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363L00000X

Addresses

Primary practice location

908 S 10TH St Ste B
Leesville, LA 71446

Mailing address

1640 Breazeale Springs St
Natchitoches, LA 71457-4278
Phone (318) 352-9299

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040807000145 LA Part B Supplier - Clinic/Group Practice 5597651794 Receives reassigned benefits from 14 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Natchitoches, LA; Tallulah, LA; Leesville, LA
O20101227000127 LA Part A Provider - Federally Qualified Health Center (FQHC) 5597651794 Practice locations: Leesville, LA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1285664508. Details of each certification follow.

Federally qualified health center certification: CCN 191806

Legal name
OUTPATIENT MEDICAL CENTER, INC.
Doing business as
OUTPATIENT MEDICAL CENTER, INC @ LEESVILLE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 1991
Last certification
Oct 1, 1991
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 23, 1998 in LA
Enrollment address
908 S 10TH St
Ste B
Leesville, LA 71446-4614

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.

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
19D0465033Outpatient Medical Center Inc at Leesville908 South 10TH Street, Suite B, Leesville, LA 71446Certificate of waiverDec 22, 2027

National Provider Directory

National Provider Directory
Tax ID family
Outpatient Medical Center Inc7 organizations share this tax ID, including this one

Other organizations with this tax ID 6

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

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Locations

1603 Boone St
Ste B
Leesville, LA 71446
Phone (800) 308-7569

908 S 10th St
Leesville, LA 71446
Phone (318) 357-2062

368 Highway 1 S
Natchitoches, LA 71457

Ownership & related parties

All disclosed owners & managing parties 9

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

NameRoleSinceShare
Travis Barnum Individual Corporate DirectorBoard Member Jan 1, 2012
Melvin Holmes Individual Corporate DirectorBoard Member Jan 1, 2012
Doris Hullalby Individual Corporate DirectorBoard Member Jan 1, 2012
Berteal Rogers Individual Corporate DirectorBoard Member Jan 1, 2012
Thomas Roque Individual Corporate DirectorBoard Member Jan 1, 2012
Diane Jones Individual Corporate DirectorBoard Member Jan 1, 2012
Roderick C Campbell Individual Corporate OfficerCeo May 1, 2026
Corporate DirectorCeo May 1, 2026 75%
W-2 Managing EmployeeAd; May 1, 2026
Arthur Ward Individual Corporate DirectorBoard Member Jan 1, 2012
Debra Jones Individual W-2 Managing EmployeeRevenue Cycle Administrator May 1, 2026

Practitioners & affiliated clinicians

Practitioners 11

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": "1151884800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1535500800000",
    "number": "1285664508",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1640 BREAZEALE SPRINGS ST",
            "city": "NATCHITOCHES",
            "state": "LA",
            "postal_code": "714574278",
            "telephone_number": "318-352-9299",
            "fax_number": "318-352-0203"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "908 S 10TH ST STE B",
            "city": "LEESVILLE",
            "state": "LA",
            "postal_code": "71446",
            "telephone_number": "337-238-1274",
            "fax_number": "337-239-2225"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "OUTPATIENT MEDICAL CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-03",
        "last_updated": "2018-08-29",
        "status": "A",
        "authorized_official_last_name": "WALTERS",
        "authorized_official_first_name": "CARL",
        "authorized_official_middle_name": "ISIAH",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "318-357-2055"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Leesville, LA

Sources for this page

Verify at the official NPI Registry.