1215074430 NPI number — DEPARTMENT OF HEALTH AND HOSPITALS

Table of content: DR. CLARA E DE JESUS DMD (NPI 1114923653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215074430 NPI number — DEPARTMENT OF HEALTH AND HOSPITALS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEPARTMENT OF HEALTH AND HOSPITALS
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:
Provider Other Organization Name Type Code:
6
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:
1215074430
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2513 FERRAND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71201-3210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-362-3270
Provider Business Mailing Address Fax Number:
318-362-3268

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
602 E GEORGIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUSTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71270-3931
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-251-4125
Provider Business Practice Location Address Fax Number:
318-251-5000
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DEBORD
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
REGIONAL ADMINISTRAT
Authorized Official Telephone Number:
318-362-3270

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  100 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1710571 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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