Basic Information
| Provider Information | |||||||||
| NPI: | 1770198681 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARILLAC COMMUNITY HEALTH CENTERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13038 | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701853038 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4000 CADILLAC ST | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701221117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5042073064 | ||||||||
| FaxNumber: | 5042822213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2020 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | GRIFFIN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5042073060 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/04/2020 | ||||||||
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.