Basic Information
| Provider Information | |||||||||
| NPI: | 1871584722 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHRISTUS HEALTH CENTRAL LOUISIANA | ||||||||
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| OtherOrganizationName: | CHRISTUS COUSHATTA RURAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 847329 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752847329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007567999 | ||||||||
| FaxNumber: | 4692821791 | ||||||||
| Practice Location | |||||||||
| Address1: | 1633 MARVEL STREET | ||||||||
| Address2: | |||||||||
| City: | COUSHATTA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710199022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189322081 | ||||||||
| FaxNumber: | 3189322215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | MONTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3374702100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 261QC0050X | 551RHC-1 | LA | Y | Ambulatory Health Care Facilities | Clinic/Center | Critical Access Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1443913 | 05 | LA | MEDICAID |