# GREEN CLINIC LLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1831178755
- **Authorized official:** LORI S KEEN (CEO)
- **Authorized official phone:** (318) 251-6304

## Contact information

- **Practice address:** 1200 S FARMERVILLE ST, RUSTON, LA 71270-5941
- **Practice address phone:** (318) 255-3690
- **Mailing address:** 1200 S FARMERVILLE ST, RUSTON, LA 71270-5941
- **Mailing address phone:** (318) 255-3690

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 133V00000X | Registered Dietitian | — | NULL | — |
| 133V00000X | Registered Dietitian | — | — | — |
| 204C00000X | Sports Medicine (Neuromusculoskeletal Medicine) Physician | — | NULL | — |
| 204C00000X | Sports Medicine (Neuromusculoskeletal Medicine) Physician | — | — | — |
| 204E00000X | Oral & Maxillofacial Surgery (D.M.D.) | — | NULL | — |
| 204E00000X | Oral & Maxillofacial Surgery (D.M.D.) | — | — | — |
| 207N00000X | Dermatology Physician | — | NULL | — |
| 207N00000X | Dermatology Physician | — | — | — |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 207R00000X | Internal Medicine Physician | — | NULL | — |
| 207R00000X | Internal Medicine Physician | — | — | — |
| 207U00000X | Nuclear Medicine Physician | — | NULL | — |
| 207U00000X | Nuclear Medicine Physician | — | — | — |
| 207V00000X | Obstetrics & Gynecology Physician | — | NULL | — |
| 207V00000X | Obstetrics & Gynecology Physician | — | — | — |
| 207W00000X | Ophthalmology Physician | — | NULL | — |
| 207W00000X | Ophthalmology Physician | — | — | — |
| 207X00000X | Orthopaedic Surgery Physician | — | NULL | — |
| 207X00000X | Orthopaedic Surgery Physician | — | — | — |
| 207Y00000X | Otolaryngology Physician | — | NULL | — |
| 207Y00000X | Otolaryngology Physician | — | — | — |
| 208000000X | Pediatrics Physician | — | NULL | — |
| 208000000X | Pediatrics Physician | — | — | — |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | NULL | — |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | — | — |
| 2083P0500X | Preventive Medicine/Occupational Environmental Medicine Physician | — | NULL | — |
| 2083P0500X | Preventive Medicine/Occupational Environmental Medicine Physician | — | — | — |
| 213E00000X | Podiatrist | — | NULL | — |
| 213E00000X | Podiatrist | — | — | — |

## Other

- **Enumeration date:** 01/10/2006
- **Last updated:** 02/22/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 06185 | BCBS GROUP | LA |
| 05 | — | 1006858 | — | LA |
| 01 | — | ========= | BCBS GROUP | LA |
| 01 | — | CS0281 | RR MEDICARE GROUP | LA |