Provider Demographics
NPI:1093874000
Name:ST GABRIEL HEALTH CLINIC INC
Entity Type:Organization
Organization Name:ST GABRIEL HEALTH CLINIC INC
Other - Org Name:
Other - Org Type:
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:
Authorized Official - Phone:225-642-9676
Mailing Address - Street 1:PO BOX 209
Mailing Address - Street 2:
Mailing Address - City:SAINT GABRIEL
Mailing Address - State:LA
Mailing Address - Zip Code:70776-0209
Mailing Address - Country:US
Mailing Address - Phone:225-642-9676
Mailing Address - Fax:225-642-9696
Practice Address - Street 1:5760 MONTICELLO DRIVE
Practice Address - Street 2:
Practice Address - City:ST GABRIEL
Practice Address - State:LA
Practice Address - Zip Code:70776
Practice Address - Country:US
Practice Address - Phone:225-642-9676
Practice Address - Fax:225-642-9696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1944114Medicaid
LA2503146Medicaid
LA2156161Medicaid
LA2191217Medicaid
LA2503341Medicaid
LA2422430Medicaid
LA1457680Medicaid