Provider Demographics
NPI:1194996025
Name:IBERVILLE ELEM SCHOOL BASE HEALTH CLINIC
Entity type:Organization
Organization Name:IBERVILLE ELEM SCHOOL BASE HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-642-9676
Mailing Address - Street 1:5760 MONTICELLO DR
Mailing Address - Street 2:
Mailing Address - City:ST GABRIEL
Mailing Address - State:LA
Mailing Address - Zip Code:70776
Mailing Address - Country:US
Mailing Address - Phone:225-642-9676
Mailing Address - Fax:225-642-9696
Practice Address - Street 1:5760 MONTICELLO DR
Practice Address - Street 2:
Practice Address - City:ST GABRIEL
Practice Address - State:LA
Practice Address - Zip Code:70776
Practice Address - Country:US
Practice Address - Phone:225-642-9676
Practice Address - Fax:225-642-9696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1457701Medicaid