Provider Demographics
NPI:1154477909
Name:CHITIMACHA TRIBE OF LOUISIANA
Entity Type:Organization
Organization Name:CHITIMACHA TRIBE OF LOUISIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR HEALTH AND HUMAN SERVICES
Authorized Official - Prefix:MS
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-923-9955
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:CHARENTON
Mailing Address - State:LA
Mailing Address - Zip Code:70523-0640
Mailing Address - Country:US
Mailing Address - Phone:337-923-9955
Mailing Address - Fax:337-923-6848
Practice Address - Street 1:3231 CHITIMACHA TRAIL
Practice Address - Street 2:
Practice Address - City:CHARENTON
Practice Address - State:LA
Practice Address - Zip Code:70523-0661
Practice Address - Country:US
Practice Address - Phone:337-923-9955
Practice Address - Fax:337-923-6848
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHITIMACHA TRIBE OF LOUISIANA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-26
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15134R261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1233978Medicaid
LATEZ062Medicare PIN