NPIMap

Organization Active NPI

David Raines Community Health Center, Inc.

Doing business as David Raines School Based Health Center-Oak Park

  • Federally Qualified Health Center (FQHC)
  • Shreveport, LA
National Provider Identifier
1760042394
Registry record updated Jun 17, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
DAVID RAINES COMMUNITY HEALTH CENTER, INC.
Doing business as
David Raines School Based Health Center-Oak Park
Practice address
4331 Henry St
Shreveport, LA 71109-6820
Phone
(318) 635-2141
NPI assigned
Jun 17, 2019
Last updated
Jun 17, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 17, 2019

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

Authorized official

Name
Mr. Willie C. White III
Title
Chief Executive Officer
Phone
(318) 227-3350

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

4331 Henry St
Shreveport, LA 71109-6820

Mailing address

3041 Martin Luther King Jr. Drive
Shreveport, LA 71107-5899
Phone (318) 227-3350

Other identifiers 1

IdentifierTypeStateIssuer
1941638MedicaidLA

Other names 1

  • David Raines School Based Health Center-Oak Park Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20041007000508 LA Part B Supplier - Clinic/Group Practice 4688586118 Receives reassigned benefits from 67 practitioners
20 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Gilliam, LA; Shreveport, LA; Minden, LA; Keithville, LA; Hayneville, LA; Bossier City, LA
O20231114000305 LA Part A Provider - Federally Qualified Health Center (FQHC) 4688586118 Practice locations: Shreveport, LA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1760042394. Details of each certification follow.

Federally qualified health center certification: CCN 191169

Legal name
DAVID RAINES COMMUNITY HEALTH CENTER, INC.
Doing business as
DAVID RAINES SBHC- OAK PARK
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 9, 2023
Last certification
Nov 9, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Aug 12, 2019 in LA
Enrollment address
4331 Henry St
Shreveport, LA 71109-6820

Other NPIs with the same Medicare PAC ID 17

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

View all 17

Other NPIs on the same Medicare enrollment 20

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

View all 20

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
19D2169581David Raines Community Health CNTR - SBHC Oak Park4331 Henry Street, Shreveport, LA 71109Certificate of waiverJul 22, 2027

National Provider Directory

National Provider Directory
Tax ID family
David Raines Community Health Center Inc26 organizations share this tax ID, including this one

Other organizations with this tax ID 25

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

View all 25

Locations

1625 David Raines Rd
Shreveport, LA 71107
Phone (318) 425-2252

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Darrell Webb Individual Corporate OfficerBoard Jan 1, 2026
Gladys Bush Individual Corporate OfficerTreasurer Jan 1, 2026
Deeandriez Wallace Individual Corporate Director Mar 1, 2022
Stephen F Wright Individual Corporate Director Mar 1, 2022
Fredrick Wilson Individual Corporate Director Mar 1, 2022
Kenya Roberts Individual Corporate OfficerBoard Jan 1, 2026
Willie C White Individual Corporate DirectorCeo May 1, 1997
W-2 Managing EmployeeCeo May 1, 1997
Todd Hollenshead Individual Corporate Director Mar 1, 2022
Myrtis Edwards Individual Corporate Officer Nov 6, 2001
Janice Sneed Individual Corporate OfficerBoard Jan 1, 2026
Ryan Williams Individual Corporate Director Mar 1, 2022

Practitioners & affiliated clinicians

Practitioners 18

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 18

NPI Registry JSON

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

{
    "created_epoch": "1560729600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1560729600000",
    "number": "1760042394",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3041 MARTIN LUTHER KING JR. DRIVE",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "711075899",
            "telephone_number": "318-227-3350",
            "fax_number": "318-222-2979"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4331 HENRY ST",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "711096820",
            "telephone_number": "318-635-2141"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DAVID RAINES COMMUNITY HEALTH CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-06-17",
        "last_updated": "2019-06-17",
        "status": "A",
        "authorized_official_last_name": "WHITE",
        "authorized_official_first_name": "WILLIE",
        "authorized_official_middle_name": "C.",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "318-227-3350",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "III"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1941638",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "David Raines School Based Health Center-Oak Park",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Shreveport, LA

Sources for this page

Verify at the official NPI Registry.