Basic Information
| Provider Information | |||||||||
| NPI: | 1326342064 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ACCESS HEALTH LOUISIANA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST CHARLES COMMUNITY HEALTH CENTER, DESTREHAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 843 MILLING AVE | ||||||||
| Address2: | |||||||||
| City: | LULING | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700704442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857855800 | ||||||||
| FaxNumber: | 9857855811 | ||||||||
| Practice Location | |||||||||
| Address1: | 843 MILLING AVE | ||||||||
| Address2: | |||||||||
| City: | LULING | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700704442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857855800 | ||||||||
| FaxNumber: | 9857855811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2011 | ||||||||
| LastUpdateDate: | 08/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | BUSSEY | ||||||||
| AuthorizedOfficialFirstName: | TRENTON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9857855800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | MD.04201R | LA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RN0300X | MD.03945R | LA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207Q00000X | MD04201R | LA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2156501 | 05 | LA | MEDICAID |