Basic Information
| Provider Information | |||||||||
| NPI: | 1699878645 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIMARY CARE PROVIDERS FOR A HEALTHY FELICIANA INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | RKM PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 395 | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707220395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256835292 | ||||||||
| FaxNumber: | 2256833411 | ||||||||
| Practice Location | |||||||||
| Address1: | 11990 JACKSON STREET | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707223210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256835292 | ||||||||
| FaxNumber: | 2256833411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 01/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUNT | ||||||||
| AuthorizedOfficialFirstName: | GINGER | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2256835292 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRIMARY CARE PROVIDERS FOR A HEALTHY FELICIANA INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | FPNP-C | ||||||||
| NPICertificationDate: | 01/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1450278 | 05 | LA | MEDICAID |