Basic Information
| Provider Information | |||||||||
| NPI: | 1023778800 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IBERIA COMPREHENSIVE COMMUNITY HEALTH CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 806 JEFFERSON TER | ||||||||
| Address2: | |||||||||
| City: | NEW IBERIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705605727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373654945 | ||||||||
| FaxNumber: | 3373640081 | ||||||||
| Practice Location | |||||||||
| Address1: | 6526 CHAISSON RD BLDG H | ||||||||
| Address2: | |||||||||
| City: | ABBEVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705105753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373654945 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2021 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | CAMPBELL | ||||||||
| AuthorizedOfficialFirstName: | RODERICK | ||||||||
| AuthorizedOfficialMiddleName: | CHARLES | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3373654945 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | IBERIA COMPREHENSIVE COMMUNITY HEALTH CENTER, INC. | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.