Provider Demographics
NPI:1922591080
Name:ACA CLINIC
Entity Type:Organization
Organization Name:ACA CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:ANDERSON
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:225-284-7158
Mailing Address - Street 1:59185 POSTELL AVE
Mailing Address - Street 2:
Mailing Address - City:PLAQUEMINE
Mailing Address - State:LA
Mailing Address - Zip Code:70764-3462
Mailing Address - Country:US
Mailing Address - Phone:225-284-7158
Mailing Address - Fax:
Practice Address - Street 1:23823 EDEN ST
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764-3315
Practice Address - Country:US
Practice Address - Phone:225-284-7158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-12
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2384201Medicaid