Basic Information
| Provider Information | |||||||||
| NPI: | 1255665832 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BATON ROUGE PRIMARY CARE COLLABORA | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ST. VINCENT DE PAUL HOMELESS CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2013 CENTRAL ROAD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708073918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257741120 | ||||||||
| FaxNumber: | 2257741158 | ||||||||
| Practice Location | |||||||||
| Address1: | 153 N. 17TH STREET | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708023813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2253439086 | ||||||||
| FaxNumber: | 2253439509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2009 | ||||||||
| LastUpdateDate: | 04/03/2012 | ||||||||
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| AuthorizedOfficialLastName: | MEDLEY-LONG | ||||||||
| AuthorizedOfficialFirstName: | LYNNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2253561864 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| 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.