Basic Information
| Provider Information | |||||||||
| NPI: | 1013204312 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MQVN COMMUNITY DEVELOPMENT CORPORATION | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NOELA COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4626 ALCEE FORTIER BOULEVARD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701292130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5042559170 | ||||||||
| FaxNumber: | 5042559190 | ||||||||
| Practice Location | |||||||||
| Address1: | 46S6 ALCEE FORTIER BLVD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701292130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5042558665 | ||||||||
| FaxNumber: | 5042348664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2011 | ||||||||
| LastUpdateDate: | 07/07/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NGUYEN | ||||||||
| AuthorizedOfficialFirstName: | DIEM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5042559170 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.