Provider Demographics
NPI: | 1437930625 |
---|---|
Name: | MARILLAC COMMUNITY HEALTH CENTER |
Entity Type: | Organization |
Organization Name: | MARILLAC COMMUNITY HEALTH CENTER |
Other - Org Name: | RESURRECTION OF OUR LORD |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | LEAD CREDENTIALING SPECIALIST |
Authorized Official - Prefix: | |
Authorized Official - First Name: | TANYELLE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | OATIS-GASKEW |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 504-212-9546 |
Mailing Address - Street 1: | PO BOX 4148 |
Mailing Address - Street 2: | |
Mailing Address - City: | NEW ORLEANS |
Mailing Address - State: | LA |
Mailing Address - Zip Code: | 70178-4148 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 504-212-9558 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 4861 ROSALIA DR |
Practice Address - Street 2: | |
Practice Address - City: | NEW ORLEANS |
Practice Address - State: | LA |
Practice Address - Zip Code: | 70127-3562 |
Practice Address - Country: | US |
Practice Address - Phone: | 504-207-3060 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2023-10-12 |
Last Update Date: | 2023-11-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QF0400X | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |