1154368553 NPI number — TECHE ACTION BOARD, INC.

Table of content: (NPI 1154368553)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154368553 NPI number — TECHE ACTION BOARD, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TECHE ACTION BOARD, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TECHE ACTION CLINIC @ EDGARD
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154368553
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1115 WEBER STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70538-4124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-828-2550
Provider Business Mailing Address Fax Number:
337-355-2335

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
159 E 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDGARD
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70049-2450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-497-8726
Provider Business Practice Location Address Fax Number:
985-497-3108
Provider Enumeration Date:
06/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILTZ
Authorized Official First Name:
GARY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
337-828-2550

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5B803 . This is a "PART B" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 2134434 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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