=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790292845
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMON GROUND HEALTH CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2018
-----------------------------------------------------
Last Update Date | 12/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 441 WALL BLVD
-----------------------------------------------------
City | GRETNA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70056-7723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-361-9800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 441 WALL BLVD
-----------------------------------------------------
City | GRETNA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70056-7723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CARLEETHA SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 504-302-2285
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------