Provider Demographics
NPI:1386880433
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:M
Authorized Official - Last Name:WILTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-828-2550
Mailing Address - Street 1:1115 WEBER STREET
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 1:473 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:RESERVE
Practice Address - State:LA
Practice Address - Zip Code:70084-5509
Practice Address - Country:US
Practice Address - Phone:985-479-1315
Practice Address - Fax:985-479-1328
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TECHE ACTION BOARD, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-19
Last Update Date:2023-07-12
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
LA1803782Medicaid
LA5B803OtherMEDICARE PART B
LA191874Medicare PIN