Provider Demographics
NPI:1093006249
Name:ST. GABRIEL HEALTH CLINIC, INC
Entity Type:Organization
Organization Name:ST. GABRIEL HEALTH CLINIC, INC
Other - Org Name:ST GABRIEL HEALTH CLINIC INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:F
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:225-642-9676
Mailing Address - Street 1:5760 MONTICELLO DR
Mailing Address - Street 2:
Mailing Address - City:SAINT GABRIEL
Mailing Address - State:LA
Mailing Address - Zip Code:70776-4412
Mailing Address - Country:US
Mailing Address - Phone:225-642-9676
Mailing Address - Fax:225-642-9696
Practice Address - Street 1:1825 HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:SAINT GABRIEL
Practice Address - State:LA
Practice Address - Zip Code:70776-5326
Practice Address - Country:US
Practice Address - Phone:225-642-9676
Practice Address - Fax:225-642-9696
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST GABRIEL HEALTH CLINIC , INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-22
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2156161Medicaid