Provider Demographics
NPI:1922279843
Name:EAST IBERVILLE ELEM/HIGH SCHOOL BASE HEALTH CLINIC
Entity Type:Organization
Organization Name:EAST IBERVILLE ELEM/HIGH SCHOOL BASE HEALTH CLINIC
Other - Org Name:ST GABRIEL HEALTH CLINIC INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:FREEMAN
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
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:225-642-3676
Mailing Address - Fax:225-642-9696
Practice Address - Street 1:3285 HIGHWAY 75
Practice Address - Street 2:
Practice Address - City:SAINT GABRIEL
Practice Address - State:LA
Practice Address - Zip Code:70776-4409
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:2008-03-19
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1457680Medicaid