Basic Information
| Provider Information | |||||||||
| NPI: | 1669443487 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLECO PRIMARY CARE NETWORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | CLECO MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 808 SCHENCK STREET | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281503934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044809344 | ||||||||
| FaxNumber: | 7044843260 | ||||||||
| Practice Location | |||||||||
| Address1: | 808 SCHENCK STREET | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044809344 | ||||||||
| FaxNumber: | 7044843260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 03/21/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JORDAN | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | HOYLE | ||||||||
| AuthorizedOfficialTitleorPosition: | FINANCIAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7044801087 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLECO PRIMARY CARE NETWORK | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 343970A | 05 | NC | MEDICAID |