Healthcare Provider Details

I. General information

NPI: 1891052254
Provider Name (Legal Business Name): JEFFERSON COMMUNITY HEALTH CARE CENTERS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2012
Last Update Date: 04/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 8TH ST
HARVEY LA
70058-4006
US

IV. Provider business mailing address

PO BOX 2490
MARRERO LA
70073-2490
US

V. Phone/Fax

Practice location:
  • Phone: 504-367-4407
  • Fax:
Mailing address:
  • Phone: 504-762-8900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: DR. CYROUS ARDALAN
Title or Position: INTERIN CEO
Credential: DDS
Phone: 504-762-8900