Provider Demographics
NPI:1831827724
Name:FIESTA HEALTH LLC
Entity type:Organization
Organization Name:FIESTA HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIEF CLINICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BOUDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:231-497-0555
Mailing Address - Street 1:634 HOLGATE AVE
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-2038
Mailing Address - Country:US
Mailing Address - Phone:912-491-2491
Mailing Address - Fax:470-329-0008
Practice Address - Street 1:800 E 70TH ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4813
Practice Address - Country:US
Practice Address - Phone:912-214-3314
Practice Address - Fax:912-722-4061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-10
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty