1962777136 NPI number — GARDERE CENTER FOR PRIMARY CARE

Table of content: (NPI 1962777136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962777136 NPI number — GARDERE CENTER FOR PRIMARY CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARDERE CENTER FOR PRIMARY CARE
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:
1962777136
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 209
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT GABRIEL
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70776-0209
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:
1707 GARDERE LN STE E
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:
70820-8166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-930-4922
Provider Business Practice Location Address Fax Number:
225-930-4926
Provider Enumeration Date:
03/20/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LEVY
Authorized Official First Name:
ASHLEY
Authorized Official Middle Name:
T
Authorized Official Title or Position:
CEO
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)

  • Identifier: 2191217 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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