Basic Information
| Provider Information | |||||||||
| NPI: | 1609066646 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOMER MEMORIAL HOSPITAL | ||||||||
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| OtherOrganizationName: | CLAIBORNE MEMORIAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 809 | ||||||||
| Address2: | 620 E COLLEGE ST. | ||||||||
| City: | HOMER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189272024 | ||||||||
| FaxNumber: | 3189729212 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 EAST COLLEGE ST. | ||||||||
| Address2: | |||||||||
| City: | HOMER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189272024 | ||||||||
| FaxNumber: | 3189279212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2007 | ||||||||
| LastUpdateDate: | 09/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | HAYNES | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3189272024 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOMER MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | RHIA | ||||||||
| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 367500000X | 206 | LA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207P00000X | 206 | LA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1705802 | 05 | LA | MEDICAID | 04802 | 01 | LA | BLUE CROSS | OTHER | 1799645 | 05 | LA | MEDICAID |