Provider Demographics
NPI:1780015784
Name:WEST JEFFERSON PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:WEST JEFFERSON PHYSICIAN SERVICES
Other - Org Name:WEST JEFFERSON DIABETES PREVENTION PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-349-6021
Mailing Address - Street 1:1101 MEDICAL CENTER BLVD.
Mailing Address - Street 2:ATTN: HEIDI GWINN
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072
Mailing Address - Country:US
Mailing Address - Phone:504-349-1297
Mailing Address - Fax:504-349-1146
Practice Address - Street 1:1121 MEDICAL CENTER BLVD.
Practice Address - Street 2:WEST JEFFERSON FITNESS CENTER
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072
Practice Address - Country:US
Practice Address - Phone:504-348-0055
Practice Address - Fax:504-347-4267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1942545Medicaid
LA5D265Medicare PIN