Provider Demographics
NPI:1235634486
Name:IBERIA COMPREHENSIVE COMMUNITY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:IBERIA COMPREHENSIVE COMMUNITY HEALTH CENTER, INC.
Other - Org Name:VERNON PARISH COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-365-4945
Mailing Address - Street 1:806 JEFFERSON TER
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-5727
Mailing Address - Country:US
Mailing Address - Phone:337-365-4945
Mailing Address - Fax:337-376-6860
Practice Address - Street 1:298 NOLAN TRACE PKWY.
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446
Practice Address - Country:US
Practice Address - Phone:337-365-4945
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IBERIA COMPREHENSIVE COMMUNITY HEALTH CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-29
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000OtherNO NUMBERS RECEIVED YET-NEW APPLICATION