Provider Demographics
NPI:1336115997
Name:CCP PRIMARY CARE CENTER
Entity Type:Organization
Organization Name:CCP PRIMARY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GROVER
Authorized Official - Middle Name:
Authorized Official - Last Name:PHIPPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-289-6690
Mailing Address - Street 1:1101 ERASTE LANDRY RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-3043
Mailing Address - Country:US
Mailing Address - Phone:337-289-6690
Mailing Address - Fax:
Practice Address - Street 1:1101 ERASTE LANDRY RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-3043
Practice Address - Country:US
Practice Address - Phone:337-289-6690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022833208VP0000X
LAAP04512363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA14-47692Medicaid
LA14-47692Medicaid