Provider Demographics
NPI:1275162141
Name:GARDEN DISTRICT TELEHEALTH CARE
Entity Type:Organization
Organization Name:GARDEN DISTRICT TELEHEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER/NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:T
Authorized Official - Last Name:GUM
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:225-936-8990
Mailing Address - Street 1:PO BOX 618
Mailing Address - Street 2:
Mailing Address - City:ARNAUDVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70512-0618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:119 FUSELIER RD
Practice Address - Street 2:
Practice Address - City:ARNAUDVILLE
Practice Address - State:LA
Practice Address - Zip Code:70512-6134
Practice Address - Country:US
Practice Address - Phone:225-936-8990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2144871Medicaid