Provider Demographics
NPI:1972739191
Name:COMMON GROUND HEALTH CLINIC
Entity type:Organization
Organization Name:COMMON GROUND HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTOR
Authorized Official - Middle Name:ODU
Authorized Official - Last Name:NDEP
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:504-365-8800
Mailing Address - Street 1:1400 TECHE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70114-5843
Mailing Address - Country:US
Mailing Address - Phone:504-365-8800
Mailing Address - Fax:504-368-9836
Practice Address - Street 1:1400 TECHE ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70114-5843
Practice Address - Country:US
Practice Address - Phone:504-365-8800
Practice Address - Fax:504-368-9836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care