1710354022 NPI number — ST GABRIEL HEALTH CLINIC, INC

Table of content: (NPI 1710354022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710354022 NPI number — ST GABRIEL HEALTH CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST GABRIEL HEALTH CLINIC, 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:
SOUTH BATON ROUGE CHARTER ACADEMY SATELLITE CLINIC
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:
1710354022
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O BOX 209
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST GABRIEL
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70776
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-642-9676
Provider Business Mailing Address Fax Number:
225-642-9696

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9211 PARKWAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-349-7489
Provider Business Practice Location Address Fax Number:
225-646-9696
Provider Enumeration Date:
08/24/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ANTWINE
Authorized Official First Name:
MARILYN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
225-642-9676

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)





Copyright © 2007-2024 www.npivalidator.com