Healthcare Provider Details

I. General information

NPI: 1821286899
Provider Name (Legal Business Name): IBERIA COMPREHENSIVE COMMUNITY HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 DERNIER STREET
ST. MARTINVILLE LA
70582
US

IV. Provider business mailing address

317 DERNIER STREET
ST. MARTINVILLE LA
70582
US

V. Phone/Fax

Practice location:
  • Phone: 337-365-4945
  • Fax: 337-367-3917
Mailing address:
  • Phone:
  • 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: MR. RODERICK CAMPBELL
Title or Position: CEO
Credential: MBA/HCM
Phone: 337-365-4945