Healthcare Provider Details

I. General information

NPI: 1154477909
Provider Name (Legal Business Name): CHITIMACHA TRIBE OF LOUISIANA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3231 CHITIMACHA TRAIL
CHARENTON LA
70523-0661
US

IV. Provider business mailing address

PO BOX 640
CHARENTON LA
70523-0640
US

V. Phone/Fax

Practice location:
  • Phone: 337-923-9955
  • Fax: 337-923-6848
Mailing address:
  • Phone: 337-923-9955
  • Fax: 337-923-6848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number15134R
License Number StateLA

VIII. Authorized Official

Name: MS. TRICIA LYNN MORA
Title or Position: DIRECTOR HEALTH AND HUMAN SERVICES
Credential:
Phone: 337-923-9955