Basic Information
| Provider Information | |||||||||
| NPI: | 1497896153 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PACER HEALTH MANAGEMENT CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTH CAMERON RURAL HEALTH CLINIC | ||||||||
| 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: | 10080 GULF HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706078672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379054111 | ||||||||
| FaxNumber: | 3379055711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 04/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | SHOEMAKER | ||||||||
| AuthorizedOfficialFirstName: | RAY | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6623211155 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PACER HEALTH MANAGEMENT CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 534 | LA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | H1471 | 01 | LA | BCBS | OTHER | 1944335 | 05 | LA | MEDICAID | H1471 | 01 | LA | BLUE CROSS RHC | OTHER |