Provider Demographics
NPI:1073157970
Name:LIFE COAST COMMUNITY HEALTH CENTER INC
Entity Type:Organization
Organization Name:LIFE COAST COMMUNITY HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-492-6170
Mailing Address - Street 1:1101 AUDUBON AVE STE S1
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4957
Mailing Address - Country:US
Mailing Address - Phone:985-492-6170
Mailing Address - Fax:
Practice Address - Street 1:1101 AUDUBON AVE STE S1
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4957
Practice Address - Country:US
Practice Address - Phone:985-492-6170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-04
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty