Basic Information
| Provider Information | |||||||||
| NPI: | 1235486226 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAPITOL CITY FAMILY HEALTH CENTER INCORPORATED | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CARESOUTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 66156 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708966156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256502000 | ||||||||
| FaxNumber: | 2256502099 | ||||||||
| Practice Location | |||||||||
| Address1: | 904 CATALPA STREET | ||||||||
| Address2: | |||||||||
| City: | DONALDSONVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252646800 | ||||||||
| FaxNumber: | 2252646630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2012 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | KENYA | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | FRONT OFFICE/BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2256502000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAPITOL CITY FAMILY HEALTH CENTER INCORPORATED | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/30/2022 | ||||||||
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 | 2317733 | 05 | LA | MEDICAID |