Collective Rural Healthcare System LLC
Organization Active NPI Rural Health Clinic/Center · Elizabeth, LA
NPI 1841908761 · NPPES record last updated Nov 11, 2022
Key facts
- NPI
- 1841908761
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- COLLECTIVE RURAL HEALTHCARE SYSTEM LLC
- Practice address
- 4855 Highway 10 West
Suite C
Elizabeth, LA 70638 - Phone
- (318) 634-5600
- Fax
- (318) 634-5602
- NPI assigned
- Nov 9, 2022
- Organization subpart
- No
Authorized official
- Name
- Alec Donovan Jeansonne
- Title
- Ceo
- Phone
- (318) 880-2144
Practitioners 10
-
Angela V Huval, LCSW
-
Ashley Sarah Farris, FNP
-
Heather Johnson Palazzo, M.S. CCC-SLP
-
Paula Weaver Gates, APRN
-
Karla Faye Carter, FNP
-
Madeleine Julie Hebert, LMSW
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in LA
Rural health clinic certification: CCN 193926
- Legal name
- COLLECTIVE RURAL HEALTHCARE SYSTEM LLC
- Doing business as
- ELIZABETH FAMILY CLINIC
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Jun 29, 2017
- Last certification
- Jun 29, 2023
- Ownership / control type
- 1B
- Most recent change of ownership
- Mar 1, 2023 (1 total)
- Organization structure
- LLC · Proprietary
- Incorporated
- Jul 21, 2022 in LA
- Enrollment address
- 4855 Highway 10 W
Ste C
Elizabeth, LA 70638-4029
All disclosed owners & managing parties 1
| Name | Role | Since | Share |
|---|---|---|---|
| Alec Donovan Jeansonne |
5% Or Greater Direct Ownership Interest |
Aug 1, 2022 | 100% |
| Corporate Officer |
Aug 1, 2022 | 100% | |
| Operational/Managerial Control |
Aug 1, 2022 | 100% |
Change-of-ownership history
| Date | Event | Counterparty |
|---|---|---|
| Mar 1, 2023 | Change of Ownership |
Elizabeth Family Clinic |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20230111000104 | LA | Part B Supplier - Clinic/Group Practice | 1254701121 |
Receives reassigned benefits from 6 practitioners Practice locations: Elizabeth, LA |
| O20230201000608 | LA | Part a Provider - Rural Health Clinic | 1254701121 | Practice locations: Elizabeth, LA |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
4855 Highway 10 West
Suite C
Elizabeth, LA 70638
Mailing address
912 Bryan St
Cottonport, LA 71327-4288
Phone (888) 995-0591
Other names
- Elizabeth Family Clinic
Other providers in Elizabeth, LA
- Stacey Accardo
- Emily Marcantel Cox
- Dodie Gordon Daniels
- Ashley Sarah Farris
- Paula Weaver Gates
- Progressive Acute Care Oakdale, LLC
All providers in Elizabeth, LA · Rural Health Clinic/Center in Louisiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 11, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.