Healthcare Provider Details

I. General information

NPI: 1790876019
Provider Name (Legal Business Name): DESTREHAN MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12604 RIVER RD
DESTREHAN LA
70047-5306
US

IV. Provider business mailing address

12604 RIVER RD
DESTREHAN LA
70047-5306
US

V. Phone/Fax

Practice location:
  • Phone: 985-764-0439
  • Fax: 985-725-1464
Mailing address:
  • Phone: 985-764-0439
  • Fax: 985-725-1464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateLA

VIII. Authorized Official

Name: DR. CHEMMALE JAYAKRISHNAN
Title or Position: PRESIDENT/DOCTOR
Credential:
Phone: 985-785-2045