Basic Information
| Provider Information | |||||||||
| NPI: | 1700832185 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LA RED HEALTH CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21444 CARMEAN WAY | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199474572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3028551233 | ||||||||
| FaxNumber: | 3028552025 | ||||||||
| Practice Location | |||||||||
| Address1: | 21444 CARMEAN WAY | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199474572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3028551233 | ||||||||
| FaxNumber: | 3028551020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 09/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | OLSON | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3028552020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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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 | 1000021647 | 05 | DE | MEDICAID |