Basic Information
| Provider Information | |||||||||
| NPI: | 1639189244 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CALDWELL MEMORIAL HOSPITAL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WINTERS CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1089 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 714181089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186496157 | ||||||||
| FaxNumber: | 3186495094 | ||||||||
| Practice Location | |||||||||
| Address1: | 421 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 714186704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186496157 | ||||||||
| FaxNumber: | 3186495094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 03/06/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ETHERIDGE | ||||||||
| AuthorizedOfficialFirstName: | RHONDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3186495094 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CALDWELL MEMORIAL HOSPITAL, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | LA | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 261QR1300X | 113RHC1 | LA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 1943991 | 05 | LA | MEDICAID |