Provider Demographics
NPI:1609136563
Name:PRIORITY HEALTH CARE
Entity Type:Organization
Organization Name:PRIORITY HEALTH CARE
Other - Org Name:MARRERO SITE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:BOUTTE
Authorized Official - Last Name:DIOUBATE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, MSHCM
Authorized Official - Phone:504-309-6522
Mailing Address - Street 1:4700 WICHERS DR STE 306
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3054
Mailing Address - Country:US
Mailing Address - Phone:504-309-6522
Mailing Address - Fax:504-309-6084
Practice Address - Street 1:4700 WICHERS DR # 304-305
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3041
Practice Address - Country:US
Practice Address - Phone:504-309-3262
Practice Address - Fax:504-309-9307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-24
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 251S00000X
LA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2407627Medicaid
LA2340930Medicaid