NPIMap

Organization Active NPI

Louisiana Family Medicine Clinic 1

  • Clinic/Center
  • Jonesboro, LA
National Provider Identifier
1548538200
Registry record updated Jun 18, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
License
025000 Issued in LA
Legal business name
LOUISIANA FAMILY MEDICINE CLINIC 1
Practice address
103 Watts St
Jonesboro, LA 71251-2053
Phone
(318) 259-1569
Fax
(318) 259-8523
NPI assigned
Dec 9, 2011
Last updated
Jun 18, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 18, 2015

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

Authorized official

Name
Dirk Timothy Rainwater, M.D.NPI 1043286230
Title
Ceo
Phone
(318) 560-3486

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X 025000 LA Primary
Urgent Care Clinic/Center 261QU0200X 025000 LA

Addresses

Primary practice location

103 Watts St
Jonesboro, LA 71251-2053

Mailing address

103 Watts St
Jonesboro, LA 71251-2053
Phone (318) 259-1569

Other identifiers 1

IdentifierTypeStateIssuer
2344188MedicaidLA

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20120627000379 LA Part B Supplier - Clinic/Group Practice 4183889009 Receives reassigned benefits from 12 practitioners
Practice locations: Bossier City, LA; Jonesboro, LA
O20150514002085 LA DME Supplier - Physician - General Practice 4183889009 Practice locations: Jonesboro, LA

National Provider Directory

National Provider Directory

Locations

2120 Airline Dr
Bossier City, LA 71111
Phone (318) 688-3350

2890 Douglas Dr
Bossier City, LA 71111
Phone (318) 294-8185

103 Watts St
Jonesboro, LA 71251
Phone (318) 259-1569

Practitioners & affiliated clinicians

Practitioners 12

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": "1323388800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1434585600000",
    "number": "1548538200",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "103 WATTS ST",
            "city": "JONESBORO",
            "state": "LA",
            "postal_code": "712512053",
            "telephone_number": "318-259-1569",
            "fax_number": "318-259-8523"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "103 WATTS ST",
            "city": "JONESBORO",
            "state": "LA",
            "postal_code": "712512053",
            "telephone_number": "318-259-1569",
            "fax_number": "318-259-8523"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LOUISIANA FAMILY MEDICINE CLINIC 1",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-12-09",
        "last_updated": "2015-06-18",
        "status": "A",
        "authorized_official_last_name": "RAINWATER",
        "authorized_official_first_name": "DIRK",
        "authorized_official_middle_name": "TIMOTHY",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "318-560-3486",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "LA",
            "license": "025000",
            "primary": true
        },
        {
            "code": "261QU0200X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Urgent Care",
            "state": "LA",
            "license": "025000",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2344188",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Jonesboro, LA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 18, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.