Healthcare Provider Details

I. General information

NPI: 1104720069
Provider Name (Legal Business Name): INNIS COMMUNITY HEALTH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77575 LANDRY DR
MARINGOUIN LA
70757-3210
US

IV. Provider business mailing address

1620 W NORTHWEST HWY STE 100
GRAPEVINE TX
76051-3219
US

V. Phone/Fax

Practice location:
  • Phone: 225-618-5015
  • Fax: 225-442-3107
Mailing address:
  • Phone: 817-572-0009
  • Fax: 817-720-1039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name: TOMI LEONARD
Title or Position: CFO
Credential:
Phone: 225-618-7132