NPIMap

CLHG-Ruston LLC

Organization Active NPI Rural Health Clinic/Center · Ruston, LA

NPI 1346904885 · NPPES record last updated Mar 13, 2024

Key facts

NPI
1346904885
Entity type
Organization (NPI type 2)
Primary specialty
Rural Health Clinic/Center 261QR1300X
Legal business name
CLHG-RUSTON LLC
Practice address
411 E Vaughn Ave Ste 104
Ruston, LA 71270-5975
Phone
(318) 254-2100
NPI assigned
Oct 29, 2021
Organization subpart
Yes
Parent organization (as reported)
CLHG-RUSTON LLC

Authorized official

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

Other NPIs on the same Medicare enrollment 4

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

Other NPIs with the same Medicare PAC ID 3

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

Corporate family (same tax ID) 8

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

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

Facilities with the same owner 48

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

View all 48

Practitioners 31

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 31

Laboratory certificates & supplier records

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

CLIA laboratory certificates

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

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in LA

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
LLC · Proprietary
Incorporated
Jan 27, 2020 in LA
Enrollment address
411 E Vaughn Ave
Ste 104
Ruston, LA 71270-5975
Related CCNs
190086

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 Director
Board Member/Coo		 Jul 1, 2020
W-2 Managing Employee
Board Member/Coo		 Jul 1, 2020
Operational/Managerial Control
Board Member/Coo		 Jul 1, 2020
Rock Bordelon
Individual 		5% Or Greater Direct Ownership Interest
Owner		 Jul 1, 2020 100%
Corporate Officer
Board 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 Director
Corporate Director		 Jan 1, 2024
W-2 Managing Employee Jan 1, 2024

Medicare enrollment records

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

National Provider Directory

Tax ID family
CLHG-Ruston LLC (9 organizations share this tax ID)
Part of
CLHG-Ruston LLC

Locations

411 E Vaughn Ave
Ste 100104105201202203
Ruston, LA 71270

Specialties & licenses

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

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

  • Allegiance Medical Clinic of Ruston Doing business as

Other providers in Ruston, LA

All providers in Ruston, LA · Rural Health Clinic/Center in Louisiana

Sources for this page

Verify at the official NPI Registry.