Healthcare Provider Details

I. General information

NPI: 1922279843
Provider Name (Legal Business Name): EAST IBERVILLE ELEM/HIGH SCHOOL BASE HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2008
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3285 HIGHWAY 75
SAINT GABRIEL LA
70776-4409
US

IV. Provider business mailing address

PO BOX 209
SAINT GABRIEL LA
70776-0209
US

V. Phone/Fax

Practice location:
  • Phone: 225-642-9676
  • Fax: 225-642-9696
Mailing address:
  • Phone: 225-642-3676
  • Fax: 225-642-9696

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: ASHLEY T LEVY
Title or Position: CEO
Credential:
Phone: 225-642-9676