NPIMap

Organization Active NPI

Collective Rural Healthcare System LLC

Doing business as Elizabeth Family Clinic

  • Rural Health Clinic/Center
  • Elizabeth, LA
National Provider Identifier
1841908761
Registry record updated Nov 11, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
COLLECTIVE RURAL HEALTHCARE SYSTEM LLC
Doing business as
Elizabeth Family Clinic
Practice address
4855 Highway 10 West
Suite C
Elizabeth, LA 70638
Phone
(318) 634-5600
Fax
(318) 634-5602
NPI assigned
Nov 9, 2022
Last updated
Nov 11, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 11, 2022

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

Authorized official

Name
Alec Donovan Jeansonne
Title
Ceo
Phone
(318) 880-2144

Specialties & licenses 1

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

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 1

  • Elizabeth Family Clinic Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1841908761. Details of each certification follow.

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
LLCProprietary
Incorporated
Jul 21, 2022 in LA
Enrollment address
4855 Highway 10 W
Ste C
Elizabeth, LA 70638-4029

National Provider Directory

National Provider Directory

Locations

4855 Highway 10
Ste C
Elizabeth, LA 70638
Phone (318) 306-6055

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
Alec Donovan Jeansonne Individual 5% Or Greater Direct Ownership InterestCeo Aug 1, 2022 100%
Corporate OfficerCeo Aug 1, 2022 100%
Operational/Managerial ControlCeo Aug 1, 2022 100%

Change-of-ownership history 1

DateEventCounterparty
Mar 1, 2023 Change of OwnershipThis provider was the buyer Elizabeth Family ClinicCCN 193926, LA, NPI 1497095681

Practitioners & affiliated clinicians

Practitioners 12

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": "1667952000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1668124800000",
    "number": "1841908761",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "912 BRYAN ST",
            "city": "COTTONPORT",
            "state": "LA",
            "postal_code": "713274288",
            "telephone_number": "888-995-0591",
            "fax_number": "318-581-9067"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4855 HIGHWAY 10 WEST",
            "address_2": "SUITE C",
            "city": "ELIZABETH",
            "state": "LA",
            "postal_code": "70638",
            "telephone_number": "318-634-5600",
            "fax_number": "318-634-5602"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COLLECTIVE RURAL HEALTHCARE SYSTEM LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-11-09",
        "last_updated": "2022-11-11",
        "certification_date": "2022-11-11",
        "status": "A",
        "authorized_official_last_name": "JEANSONNE",
        "authorized_official_first_name": "ALEC",
        "authorized_official_middle_name": "DONOVAN",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "318-880-2144"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Elizabeth Family Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Elizabeth Family Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Elizabeth, LA

Sources for this page

Verify at the official NPI Registry.