NPIMap

Organization Active NPI

Kentwood Family Clinic LLC

  • Rural Health Clinic/Center
  • Kentwood, LA
National Provider Identifier
1780050294
Registry record updated Mar 2, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
KENTWOOD FAMILY CLINIC LLC
Practice address
919 Avenue G
Kentwood, LA 70444
Phone
(337) 991-9276
Fax
(337) 991-9288
NPI assigned
Aug 19, 2015
Last updated
Mar 2, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 2, 2020

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

Authorized official

Name
Nicole Howard
Title
Ceo
Phone
(337) 991-9276

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary
Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363L00000X
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X

Addresses

Primary practice location

919 Avenue G
Kentwood, LA 70444

Mailing address

1509 Dulles Dr
Lafayette, LA 70506-3718
Phone (337) 991-9276

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20151014000474 LA Part B Supplier - Clinic/Group Practice 4082923099 Receives reassigned benefits from 3 practitioners
Practice locations: Kentwood, LA
O20181112002051 LA Part A Provider - Rural Health Clinic 4082923099 Practice locations: Kentwood, LA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1780050294. Details of each certification follow.

Rural health clinic certification: CCN 193950

Legal name
KENTWOOD FAMILY CLINIC LLC
Doing business as
HD CONSULTING
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Oct 25, 2019
Last certification
Oct 25, 2025
Ownership / control type
1B
Organization structure
LLCProprietary
Incorporated
Jun 5, 2015 in LA
Enrollment address
919 Avenue G
Kentwood, LA 70444-2636

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
19D2103494Kentwood Family Clinic LLC919 Avenue G, Kentwood, LA 70444Certificate of waiverOct 13, 2027

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 1

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

NameRoleSinceShare
Bryan D Tate Individual 5% Or Greater Direct Ownership InterestChief Executive Officer Jun 5, 2015 100%
Corporate OfficerChief Executive Officer Jun 5, 2015 100%
Operational/Managerial ControlChief Executive Officer Jun 5, 2015 100%

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 4

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": "1439942400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1583107200000",
    "number": "1780050294",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1509 DULLES DR",
            "city": "LAFAYETTE",
            "state": "LA",
            "postal_code": "705063718",
            "telephone_number": "337-991-9276",
            "fax_number": "337-991-9288"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "919 AVENUE G",
            "city": "KENTWOOD",
            "state": "LA",
            "postal_code": "70444",
            "telephone_number": "337-991-9276",
            "fax_number": "337-991-9288"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KENTWOOD FAMILY CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-08-19",
        "last_updated": "2020-03-02",
        "certification_date": "2020-03-02",
        "status": "A",
        "authorized_official_last_name": "HOWARD",
        "authorized_official_first_name": "NICOLE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "337-991-9276"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Kentwood, LA

Sources for this page

Verify at the official NPI Registry.