Provider Demographics
NPI:1821286899
Name:IBERIA COMPREHENSIVE COMMUNITY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:IBERIA COMPREHENSIVE COMMUNITY HEALTH CENTER, INC.
Other - Org Name:ST. MARTIN PARISH COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:MBA/HCM
Authorized Official - Phone:337-365-4945
Mailing Address - Street 1:317 DERNIER STREET
Mailing Address - Street 2:
Mailing Address - City:ST. MARTINVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70582
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:317 DERNIER STREET
Practice Address - Street 2:
Practice Address - City:ST. MARTINVILLE
Practice Address - State:LA
Practice Address - Zip Code:70582
Practice Address - Country:US
Practice Address - Phone:337-365-4945
Practice Address - Fax:337-367-3917
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IBERIA COMPREHENSIVE COMMUNITY HEALTH CENTER,INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-04
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1028088Medicaid
LA1028088Medicaid