Basic Information
Provider Information | |||||||||
NPI: | 1386784569 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CATAHOULA PARISH HOSPITAL DISTRICT NO 2 | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CATAHOULA PARISH HOSPITAL DIST. #2 | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 269 | ||||||||
Address2: | 126 WATSON STREET | ||||||||
City: | WISNER | ||||||||
State: | LA | ||||||||
PostalCode: | 713780269 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3187247008 | ||||||||
FaxNumber: | 3187247646 | ||||||||
Practice Location | |||||||||
Address1: | 126 WATSON STREET | ||||||||
Address2: |   | ||||||||
City: | WISNER | ||||||||
State: | LA | ||||||||
PostalCode: | 713780269 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3187247008 | ||||||||
FaxNumber: | 3187247646 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/07/2007 | ||||||||
LastUpdateDate: | 05/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MIESCH | ||||||||
AuthorizedOfficialFirstName: | DEBRA | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 3183895727 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MBA | ||||||||
NPICertificationDate: | 05/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   | LA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 1946036 | 05 | LA |   | MEDICAID | 10464 | 01 | LA | BLUE CROSS LA | OTHER | 1903191 | 05 | LA |   | MEDICAID |