Basic Information
Provider Information | |||||||||
NPI: | 1437258043 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRIMARY CARE PROVIDERS FOR A HEALTHY FELICIANA, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | JACKSON COMPLEX HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 395 | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | LA | ||||||||
PostalCode: | 707220395 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2256835292 | ||||||||
FaxNumber: | 2256831310 | ||||||||
Practice Location | |||||||||
Address1: | 3619 HIGHWAY 10 | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | LA | ||||||||
PostalCode: | 70748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2256831360 | ||||||||
FaxNumber: | 2256340005 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/21/2006 | ||||||||
LastUpdateDate: | 04/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUNT | ||||||||
AuthorizedOfficialFirstName: | CHRISTI | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2256835292 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PRIMARY CARE PROVIDERS FOR A HEALTHY FELICIANA, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   | LA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 1448389 | 05 | LA |   | MEDICAID |