Provider Demographics
NPI:1215354014
Name:TECHE ACTION BOARD, INC.
Entity type:Organization
Organization Name:TECHE ACTION BOARD, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-828-2550
Mailing Address - Street 1:1115 WEBER ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:LA
Mailing Address - Zip Code:70538-4124
Mailing Address - Country:US
Mailing Address - Phone:337-828-2550
Mailing Address - Fax:337-355-2335
Practice Address - Street 1:121 WEST 134TH PLACE
Practice Address - Street 2:
Practice Address - City:GALLIANO
Practice Address - State:LA
Practice Address - Zip Code:70354
Practice Address - Country:US
Practice Address - Phone:337-828-2550
Practice Address - Fax:337-355-2335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2381849Medicaid
LA5B803OtherMEDICARE PART B
LA191926Medicare Oscar/Certification