Green Clinic LLC

Primary specialty

Rural Health Clinic/CenterTaxonomy code 261QR1300X

Legal business name

GREEN CLINIC LLC

Doing business as

Quickcare of Ruston

Practice address

1809 Northpointe LN Ste 102
Ruston, LA 71270-3852

Phone

(318) 255-3762

NPI assigned

Mar 4, 2019

Last updated

Mar 4, 2019By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Christopher Anding Stegall

Title

Cfo

Phone

(318) 251-6304

Specialties & licenses 1

Addresses

Other names 1

• QUICKCARE OF RUSTON Doing business as

Medicare fee-for-service enrollment

Enrolled in LA2 enrollments

Enrollment records 2

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1578021093. Details of each certification follow.

• CCN 193963 Rural health clinic · Active · Details

Rural health clinic certification: CCN 193963

Legal name

GREEN CLINIC LLC

Doing business as

QUICKCARE OF RUSTON

Certification status

Active

Provider type (POS)

Rural health clinic

Participating since

Jun 23, 2020

Last certification

Jun 30, 2023

Ownership / control type

1B

Organization structure

LLCProprietary

Incorporated

in LA

Enrollment address

1420 Commerce St
Ste 1
Ruston, LA 71270-6653

Other NPIs with the same Medicare PAC ID 2

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

• Green Clinic LLC

  • Family Medicine Physician
  • Ruston, LA
  • NPI 1831178755

  4789668831

  Same PAC ID
• Green Clinic LLC

  dba Green Clinic Rehabilitation Services

  • Physical Therapy Clinic/Center
  • Ruston, LA
  • NPI 1891801601

  4789668831

  Same PAC ID

Other NPIs on the same Medicare enrollment 1

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

• Green Clinic LLC

  • Family Medicine Physician
  • Ruston, LA
  • NPI 1831178755

  O20040616000177

  Same enrollment

Tax ID family

Green Clinic Surgery Ce2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

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

• Green Clinic LLC

  dba Green Clinic Pharmacy

  • Community/Retail Pharmacy
  • Ruston, LA
  • NPI 1275632036
  NPD tax ID

Locations

All disclosed owners & managing parties 2

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

Practitioners 68

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.

• Johnathan C Baines, MD

  • Family Medicine Physician
  • Ruston, LA
  • NPI 1679769889
  NPD
• Kristina D Barber, NP

  • Family Nurse Practitioner
  • Ruston, LA
  • NPI 1043801954
  NPD
• Cynthia Petrus Bimle, MD

  • Pediatrics Physician
  • West Monroe, LA
  • NPI 1578573630
  NPD
• Cody Blackwelder, MD

  • Surgery Physician
  • Ruston, LA
  • NPI 1548824873
  NPD
• Mark Blackwelder, M.D.

  • Internal Medicine Physician
  • Ruston, LA
  • NPI 1245200880
  NPD
• Thomas G. Block III, DO

  • Diagnostic Radiology Physician
  • West Monroe, LA
  • NPI 1265096390
  NPD
• Taylor Blake Boggs, APRN, FNP-C

  • Family Nurse Practitioner
  • Ruston, LA
  • NPI 1437937125
  NPD
• Kevin Jeffrey Bunn, MD

  • Orthopaedic Surgery Physician
  • Monroe, LA
  • NPI 1205061504
  NPD
• Greene Butler, M.D.

  • Surgery Physician
  • Ruston, LA
  • NPI 1619947629
  NPD
• Kerry Wayne Byrnes, M.D.

  • Surgery Physician
  • Ruston, LA
  • NPI 1982787099
  NPD
• Bernie M Caldwell, PA-C

  • Physician Assistant
  • West Monroe, LA
  • NPI 1164407896
  NPD
• Hunter T. Christy, MD

  • Diagnostic Radiology Physician
  • West Monroe, LA
  • NPI 1699162206
  NPD

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

{
    "created_epoch": "1551657600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1551657600000",
    "number": "1578021093",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 S FARMERVILLE ST",
            "city": "RUSTON",
            "state": "LA",
            "postal_code": "712705941"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1809 NORTHPOINTE LN STE 102",
            "city": "RUSTON",
            "state": "LA",
            "postal_code": "712703852",
            "telephone_number": "318-255-3762"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREEN CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-03-04",
        "last_updated": "2019-03-04",
        "status": "A",
        "authorized_official_last_name": "STEGALL",
        "authorized_official_first_name": "CHRISTOPHER",
        "authorized_official_middle_name": "ANDING",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "318-251-6304"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "QUICKCARE OF RUSTON",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Alexis Gray, RD, LDN
• Latrice Gray
• Rel Larkin Gray, MD
• Green Clinic LLC (Green Clinic Pharmacy)
• Green Clinic LLC
• Green Clinic LLC
• Green Clinic LLC (Green Clinic Rehabilitation Services)
• Green Clinic Surgical Center
• Green Clinic Surgical Hospital Crna Group
• Green Clinic Surgical Hospital, LLC

• Rural Health Clinic/Center in Ruston, LA
• Providers in Ruston, LA by specialty
• Rural Health Clinic/Center in Louisiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 4, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.