Basic Information
Provider Information | |||||||||
NPI: | 1265548614 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CAPITOL CITY FAMILY HEALTH CENTER INCORPORATED | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CARESOUTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 66156 | ||||||||
Address2: |   | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708966156 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2256502000 | ||||||||
FaxNumber: | 2256502099 | ||||||||
Practice Location | |||||||||
Address1: | 3140 FLORIDA STREET | ||||||||
Address2: |   | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 70806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2256502000 | ||||||||
FaxNumber: | 2256502099 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/21/2006 | ||||||||
LastUpdateDate: | 06/30/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NELSON | ||||||||
AuthorizedOfficialFirstName: | KENYA | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING/CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2256502000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
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 | 1948055 | 05 | LA |   | MEDICAID |