Basic Information
| Provider Information | |||||||||
| NPI: | 1538700968 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARILLAC COMMUNITY HEALTH CENTERS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DEPAUL COMMUNITY HEALTH CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13038 | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701853038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5042073060 | ||||||||
| FaxNumber: | 5044836016 | ||||||||
| Practice Location | |||||||||
| Address1: | 3128 CONSTANCE ST | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701152337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5042820089 | ||||||||
| FaxNumber: | 5042820338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2019 | ||||||||
| LastUpdateDate: | 09/08/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRIFFIN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 5042073060 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/08/2020 | ||||||||
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.