NPIMap

Organization Active NPI

CLHG-Ruston LLC

Doing business as Allegiance Medical Clinic of Ruston

  • Rural Health Clinic/Center
  • Ruston, LA
National Provider Identifier
1346904885
Registry record updated Mar 13, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
CLHG-RUSTON LLC
Doing business as
Allegiance Medical Clinic of Ruston
Practice address
411 E Vaughn Ave Ste 104
Ruston, LA 71270-5975
Phone
(318) 254-2100
NPI assigned
Oct 29, 2021
Last updated
Mar 13, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
CLHG-RUSTON LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 13, 2024

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

Authorized official

Name
Kathy Hall
Title
Regional Clinic Operations
Phone
(318) 254-2589

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Oral & Maxillofacial Surgery (D.M.D.)Group: 193200000X MULTI-SPECIALTY GROUP 204E00000X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Pulmonary Disease PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207RP1001X
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X
Multi-Specialty Clinic/Center 261QM1300X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

411 E Vaughn Ave Ste 104
Ruston, LA 71270-5975

Mailing address

401 E Vaughn Ave
Ruston, LA 71270-5950
Phone (318) 254-2453

Other names 1

  • Allegiance Medical Clinic of Ruston Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20211210001606 LA Part A Provider - Rural Health Clinic 7315361425 Practice locations: Ruston, LA
O20220718002173 LA Part B Supplier - Clinic/Group Practice 7315361425 Receives reassigned benefits from 41 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Ruston, LA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1346904885. Details of each certification follow.

Rural health clinic certification: CCN 198546

Legal name
CLHG-RUSTON LLC
Doing business as
ALLEGIANCE MEDICAL CLINIC OF RUSTON
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Nov 27, 2023
Last certification
Nov 27, 2023
Ownership / control type
1B
Organization structure
LLCProprietary
Incorporated
Jan 27, 2020 in LA
Enrollment address
411 E Vaughn Ave
Ste 104
Ruston, LA 71270-5975
Related CCNs
190086

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 3

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

Other NPIs on the same Medicare enrollment 4

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
19D2263837Allegiance Medical Clinic of Ruston411 East Vaughn Avenue, Suite 104, Ruston, LA 71270Certificate of waiverJul 5, 2028

National Provider Directory

National Provider Directory
Tax ID family
CLHG-Ruston LLC9 organizations share this tax ID, including this one
Part of
CLHG-Ruston LLC

Other organizations with this tax ID 8

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

Locations

1420 Commerce St
#1
Ruston, LA 71270

401 E Vaughn Ave
Ruston, LA 71270
Phone (318) 254-2100

411 E Vaughn Ave
Ste 100104105201202203
Ruston, LA 71270

411 E Vaughn Ave
Ste 104
Ruston, LA 71270
Phone (318) 254-2453

Ownership & related parties

All disclosed owners & managing parties 4

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

NameRoleSinceShare
Donald Cameron Individual Corporate DirectorBoard Member/Coo Jul 1, 2020
W-2 Managing EmployeeBoard Member/Coo Jul 1, 2020
Operational/Managerial ControlBoard Member/Coo Jul 1, 2020
Rock Bordelon Individual 5% Or Greater Direct Ownership InterestOwner Jul 1, 2020 100%
Corporate OfficerBoard Member Jul 1, 2020
Operational/Managerial Control Jul 1, 2020
Allegiance Health Management Inc Organization, Shreveport, LA Corporation, Management services company Operational/Managerial Control Jul 1, 2020
Tubassam Abbasi Individual Corporate DirectorCorporate Director Jan 1, 2024
W-2 Managing Employee Jan 1, 2024

Facilities with the same owner 48

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 48

Practitioners & affiliated clinicians

Practitioners 26

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 26

NPI Registry JSON

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

{
    "created_epoch": "1635465600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1710288000000",
    "number": "1346904885",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "401 E VAUGHN AVE",
            "city": "RUSTON",
            "state": "LA",
            "postal_code": "712705950",
            "telephone_number": "318-254-2453"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "411 E VAUGHN AVE STE 104",
            "city": "RUSTON",
            "state": "LA",
            "postal_code": "712705975",
            "telephone_number": "318-254-2100"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLHG-RUSTON LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CLHG-RUSTON LLC",
        "enumeration_date": "2021-10-29",
        "last_updated": "2024-03-13",
        "certification_date": "2024-03-13",
        "status": "A",
        "authorized_official_last_name": "HALL",
        "authorized_official_first_name": "KATHY",
        "authorized_official_title_or_position": "REGIONAL CLINIC OPERATIONS",
        "authorized_official_telephone_number": "318-254-2589"
    },
    "taxonomies": [
        {
            "code": "204E00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Oral & Maxillofacial Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RP1001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Pulmonary Disease",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "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
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Allegiance Medical Clinic of Ruston",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Allegiance Medical Clinic of Ruston",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Ruston, LA

Sources for this page

Verify at the official NPI Registry.