Provider Demographics
NPI:1912139684
Name:ST. GABRIEL HEALTH CLINIC, INC.
Entity Type:Organization
Organization Name:ST. GABRIEL HEALTH CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:
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:225-642-9676
Mailing Address - Fax:225-642-9696
Practice Address - Street 1:13770 HWY 77
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:LA
Practice Address - Zip Code:70772-0200
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:2009-08-14
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)