NPIMap

Organization Active NPI

CLHG-Leesville

Doing business as West Louisiana Family Practice-Deridder

  • Rural Health Clinic/Center
  • Deridder, LA
National Provider Identifier
1831659333
Registry record updated Mar 16, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
CLHG-LEESVILLE
Doing business as
West Louisiana Family Practice-Deridder
Practice address
412 S Pine St
Deridder, LA 70634-4840
Phone
(337) 462-5700
Fax
(337) 462-6856
NPI assigned
Mar 21, 2019
Last updated
Mar 16, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 16, 2023

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

Authorized official

Name
Donald E. Cameron
Title
Board Member
Phone
(318) 226-8202

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

412 S Pine St
Deridder, LA 70634-4840

Mailing address

1020 W Fertitta Blvd
Leesville, LA 71446-4645
Phone (337) 239-9401

Other names 1

  • West Louisiana Family Practice-Deridder Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20190503001393 LA Part A Provider - Rural Health Clinic 4082963301 Practice locations: Deridder, LA
O20200310000179 LA Part B Supplier - Clinic/Group Practice 4082963301 Receives reassigned benefits from 28 practitioners
8 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Deridder, LA; Leesville, LA; Rosepine, LA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1831659333. Details of each certification follow.

Rural health clinic certification: CCN 198515

Legal name
CLHG-LEESVILLE
Doing business as
WEST LOUISIANA FAMILY PRACTICE-DERIDDER
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Oct 28, 2019
Last certification
Oct 28, 2025
Ownership / control type
For profit – corporation
Organization structure
LLCProprietary
Enrollment address
412 S Pine St
Deridder, LA 70634-4840
Related CCNs
190164

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

Other NPIs with the same Medicare PAC ID 9

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

Other NPIs on the same Medicare enrollment 8

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

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
19D0903434West Louisiana Family Practice-Deridder412 South Pine Street, Deridder, LA 70634Certificate of waiverFeb 14, 2028

National Provider Directory

National Provider Directory
Tax ID family
CLHG-Leesville LLC13 organizations share this tax ID, including this one

Other organizations with this tax ID 12

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

Ownership & related parties

All disclosed owners & managing parties 5

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 5% Or Greater Indirect Ownership InterestBoard Member Jun 1, 2018 16%
Corporate OfficerBoard Member Jul 31, 2019
Corporate DirectorBoard Member Jul 31, 2019
Operational/Managerial ControlBoard Member Jul 31, 2019
Rock Bordelon Individual 5% Or Greater Direct Ownership Interest Jul 31, 2019 80%
Corporate OfficerBoard Member Jul 31, 2019
Kevin Quinn Individual Corporate OfficerCeo Jan 1, 2024 100%
Corporate DirectorCeo Jan 1, 2024 100%
Operational/Managerial ControlCeo Jan 1, 2024 100%
Allegiance Health Management Inc Organization, Shreveport, LA Corporation, For-profit Operational/Managerial Control Jul 31, 2019
Cameron Investments LLC Organization, Shreveport, LA LLC, For-profit 5% Or Greater Direct Ownership Interest Jul 31, 2019 16%

Facilities with the same owner 53

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

View all 53

Practitioners & affiliated clinicians

Practitioners 3

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": "1553126400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1678924800000",
    "number": "1831659333",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1020 W FERTITTA BLVD",
            "city": "LEESVILLE",
            "state": "LA",
            "postal_code": "714464645",
            "telephone_number": "337-239-9401",
            "fax_number": "318-239-5360"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "412 S PINE ST",
            "city": "DERIDDER",
            "state": "LA",
            "postal_code": "706344840",
            "telephone_number": "337-462-5700",
            "fax_number": "337-462-6856"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLHG-LEESVILLE",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-03-21",
        "last_updated": "2023-03-16",
        "certification_date": "2023-03-16",
        "status": "A",
        "authorized_official_last_name": "CAMERON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "E.",
        "authorized_official_title_or_position": "BOARD MEMBER",
        "authorized_official_telephone_number": "318-226-8202"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "West Louisiana Family Practice-Deridder",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "West Louisiana Family Practice-Deridder",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Deridder, LA

Sources for this page

Verify at the official NPI Registry.