Provider Demographics
NPI:1578744470
Name:MGA GASTROINTESTINAL DIAGNOSTIC & THERAPEUTIC CENTER
Entity Type:Organization
Organization Name:MGA GASTROINTESTINAL DIAGNOSTIC & THERAPEUTIC CENTER
Other - Org Name:MGA GASTROINTESTINAL DIAGNOSTIC & THERAPEUTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MANAGER OF LLC
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:PO BOX 1187
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70073-1187
Mailing Address - Country:US
Mailing Address - Phone:504-896-8680
Mailing Address - Fax:504-896-8699
Practice Address - Street 1:2633 NAPOLEON AVE
Practice Address - Street 2:SUITE 707
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-6357
Practice Address - Country:US
Practice Address - Phone:504-896-8680
Practice Address - Fax:504-896-8699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1966339Medicaid
LA11048Medicare PIN