Basic Information
| Provider Information | |||||||||
| NPI: | 1114341666 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IBERIA COMPREHENSIVE COMMUNITY HEALTH CENTER, INC. | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SABINE COMPREHENSIVE HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 806 JEFFERSON TER | ||||||||
| Address2: | |||||||||
| City: | NEW IBERIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705605727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373654945 | ||||||||
| FaxNumber: | 3373673917 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 N ROBINSON ST | ||||||||
| Address2: | |||||||||
| City: | MANY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 714493536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182568150 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2014 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CAMPBELL | ||||||||
| AuthorizedOfficialFirstName: | RODERICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3373654945 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | IBERIA COMPREHENSIVE COMMUNITY HEALTH CENTER, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | 12/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 2355023 | 05 | LA | MEDICAID |