| |
1530 Gravier Street New Orleans LA 70112 | |
(504) 658-2785 | |
(504) 658-2874 |
Full Name | |
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Speciality | Clinic/Center |
Location | 1530 Gravier Street, New Orleans, Louisiana |
Authorized Official Name and Position | Tevince Forest (ACCOUNTANT) |
Authorized Official Contact | 5046582576 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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2222 Simon Bolivar Ave Fl 2 New Orleans LA 70113-1460 Ph: (504) 658-2785 | 1530 Gravier Street New Orleans LA 70112 Ph: (504) 658-2785 |
NPI Number | 1295149219 |
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Provider Enumeration Date | 06/18/2014 |
Last Update Date | 10/15/2019 |
Medicare PECOS PAC ID | 5092731505 |
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Medicare Enrollment ID | O20191016001184 |
Identifier | Type | State | Issuer |
---|---|---|---|
1295149219 | NPI | - | NPPES |
7260000969 | Medicaid | LA |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (Louisiana) | Primary |
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