Full Name | |
---|---|
Speciality | Clinic/Center |
Location | 200 Tiger Dr, Boutte, Louisiana |
Authorized Official Name and Position | Mark Keiser (CEO) |
Authorized Official Contact | 5045753700 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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2900 Indiana Ave Kenner LA 70065-4605 Ph: (504) 575-3712 | 200 Tiger Dr Boutte LA 70039-3520 Ph: (866) 530-6111 |
NPI Number | 1285393736 |
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Provider Enumeration Date | 12/13/2021 |
Last Update Date | 04/20/2022 |
Medicare PECOS PAC ID | 3678484276 |
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Medicare Enrollment ID | O20220511001050 |
Identifier | Type | State | Issuer |
---|---|---|---|
1285393736 | NPI | - | NPPES |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |