Full Name | |
---|---|
Speciality | Clinic/Center |
Location | 159 E 3rd St, Edgard, Louisiana |
Authorized Official Name and Position | Gary M Wiltz (CHIEF EXECUTIVE OFFICER) |
Authorized Official Contact | 3378282550 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
---|---|
1115 Weber Street Franklin LA 70538-4124 Ph: (337) 828-2550 | 159 E 3rd St Edgard LA 70049-2450 Ph: (985) 497-8726 |
NPI Number | 1154368553 |
---|---|
Provider Enumeration Date | 06/02/2006 |
Last Update Date | 07/12/2023 |
Medicare PECOS PAC ID | 0648163980 |
---|---|
Medicare Enrollment ID | O20101122000722 |
Identifier | Type | State | Issuer |
---|---|---|---|
1154368553 | NPI | - | NPPES |
5B803 | Other | LA | PART B |
2134434 | Medicaid | LA |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |