Provider Demographics
NPI:1306800271
Name:FLORIDA PARISHES HUMAN SERVICES AUTHORITY / FONTAINEBLEAU TX CENTER
Entity type:Organization
Organization Name:FLORIDA PARISHES HUMAN SERVICES AUTHORITY / FONTAINEBLEAU TX CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:ALI
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-624-4100
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70470-0037
Mailing Address - Country:US
Mailing Address - Phone:985-624-4100
Mailing Address - Fax:985-624-4123
Practice Address - Street 1:23861 ROBIN ROAD & HWY 190
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70447-0000
Practice Address - Country:US
Practice Address - Phone:985-624-4100
Practice Address - Fax:985-624-4123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA240324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility