Provider Demographics
NPI:1891000667
Name:GRACE OUTREACH CENTER
Entity Type:Organization
Organization Name:GRACE OUTREACH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PASTOR/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:NOAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-913-5452
Mailing Address - Street 1:2533 LASALLE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70113-2531
Mailing Address - Country:US
Mailing Address - Phone:504-913-5452
Mailing Address - Fax:504-367-6601
Practice Address - Street 1:2533 LASALLE ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70113-2531
Practice Address - Country:US
Practice Address - Phone:504-913-5452
Practice Address - Fax:504-367-6601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA453251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0000000Medicaid