Provider Demographics
NPI:1164687307
Name:CHRISTUS HEALTH CENTRAL LOUISIANA
Entity Type:Organization
Organization Name:CHRISTUS HEALTH CENTRAL LOUISIANA
Other - Org Name:PROVENCAL SBHC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MONTE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-470-2100
Mailing Address - Street 1:3330 MASONIC DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3841
Mailing Address - Country:US
Mailing Address - Phone:318-483-4031
Mailing Address - Fax:318-483-4044
Practice Address - Street 1:132 CHERRY ST
Practice Address - Street 2:
Practice Address - City:PROVENCAL
Practice Address - State:LA
Practice Address - Zip Code:71468
Practice Address - Country:US
Practice Address - Phone:318-472-8660
Practice Address - Fax:318-472-8661
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHRISTUS HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-28
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA234261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1808814Medicaid