Basic Information
| Provider Information | |||||||||
| NPI: | 1437395456 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RURAL HEALTHCARE DEVELOPERS OF LOUISIANA LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTH CAMERON MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5360 W CREOLE HWY | ||||||||
| Address2: | |||||||||
| City: | CAMERON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706315127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375424111 | ||||||||
| FaxNumber: | 3375424110 | ||||||||
| Practice Location | |||||||||
| Address1: | 5360 W CREOLE HWY | ||||||||
| Address2: | |||||||||
| City: | CAMERON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706315127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375424111 | ||||||||
| FaxNumber: | 3375424110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2008 | ||||||||
| LastUpdateDate: | 12/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | SHOEMAKER | ||||||||
| AuthorizedOfficialFirstName: | RAY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6623211155 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 534 | LA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1732095 | 05 | LA | MEDICAID |