Provider Demographics
NPI:1659493716
Name:GREATER FELLOWSHIP OUTREACH CENTER, INC.
Entity Type:Organization
Organization Name:GREATER FELLOWSHIP OUTREACH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KEISHA
Authorized Official - Middle Name:C
Authorized Official - Last Name:DAISY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-931-3571
Mailing Address - Street 1:11752 S HARRELLS FERRY RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-2387
Mailing Address - Country:US
Mailing Address - Phone:225-292-9628
Mailing Address - Fax:225-292-9623
Practice Address - Street 1:11752 S HARRELLS FERRY RD
Practice Address - Street 2:SUITE E
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-2387
Practice Address - Country:US
Practice Address - Phone:225-292-9628
Practice Address - Fax:225-292-9623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA79353747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1432512Medicaid