Provider Demographics
NPI:1710292909
Name:ST GABRIEL HEALTH CLINIC, INC.
Entity Type:Organization
Organization Name:ST GABRIEL HEALTH CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:B
Authorized Official - Last Name:ANTWINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-642-9676
Mailing Address - Street 1:5760 MONTICELLO DR
Mailing Address - Street 2:P O BOX 209
Mailing Address - City:SAINT GABRIEL
Mailing Address - State:LA
Mailing Address - Zip Code:70776-4412
Mailing Address - Country:US
Mailing Address - Phone:225-642-9676
Mailing Address - Fax:225-642-9696
Practice Address - Street 1:5760 MONTICELLO DR
Practice Address - Street 2:
Practice Address - City:SAINT GABRIEL
Practice Address - State:LA
Practice Address - Zip Code:70776-4412
Practice Address - Country:US
Practice Address - Phone:225-642-9676
Practice Address - Fax:225-642-9696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06223363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty