1518211853 NPI number — BAKER SCHOOL BASED HEALTH CLINIC

Table of content: PHILLIP NGUYEN COOLEY L.AC. (NPI 1629238605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518211853 NPI number — BAKER SCHOOL BASED HEALTH CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAKER SCHOOL BASED HEALTH CLINIC
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:
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:
1518211853
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 149
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROSSE TETE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70740-0149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-648-3433
Provider Business Mailing Address Fax Number:
877-580-7773

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3033 RAY WEILAND DR # B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAKER
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70714-3251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-978-5909
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LEONARD-HUGHES
Authorized Official First Name:
LATOYA
Authorized Official Middle Name:
Authorized Official Title or Position:
CO-OWNER/FNP
Authorized Official Telephone Number:
225-978-5909

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1454711 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1304450 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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