Provider Demographics
NPI:1780190322
Name:CONCORDIA PARISH HOSPITAL SERVICE DISTRICT NUMBER ONE
Entity Type:Organization
Organization Name:CONCORDIA PARISH HOSPITAL SERVICE DISTRICT NUMBER ONE
Other - Org Name:TRINITY MEDICAL VIDALIA CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NEKEISHA
Authorized Official - Middle Name:LASHAY
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-719-3636
Mailing Address - Street 1:PO BOX 111
Mailing Address - Street 2:
Mailing Address - City:FERRIDAY
Mailing Address - State:LA
Mailing Address - Zip Code:71334-0111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1643 CARTER ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-3156
Practice Address - Country:US
Practice Address - Phone:318-336-8707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-19
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2481011Medicaid