Provider Demographics
NPI:1710475496
Name:ST GABRIEL HEALTH CLINIC , INC
Entity Type:Organization
Organization Name:ST GABRIEL HEALTH CLINIC , INC
Other - Org Name:ST. GABRIEL - IDEA BRIDGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:BROWN
Authorized Official - Last Name:ANTWINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-642-9676
Mailing Address - Street 1:PO BOX 209
Mailing Address - Street 2:
Mailing Address - City:SAINT GABRIEL
Mailing Address - State:LA
Mailing Address - Zip Code:70776-0209
Mailing Address - Country:US
Mailing Address - Phone:225-642-9676
Mailing Address - Fax:225-642-9696
Practice Address - Street 1:1500 N AIRWAY DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70815-8060
Practice Address - Country:US
Practice Address - Phone:225-642-9676
Practice Address - Fax:225-642-9696
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST GABRIEL HEALTH CLINIC , INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)