MEDICARE: MARILLAC COMMUNITY HEALTH CENTERS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center
2	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1346615275
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARILLAC COMMUNITY HEALTH CENTERS

Provider Business Mailing Address
First Line	:	PO BOX 13038
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70185-3038
Country	:	US
Telephone Number	:	504-207-3060
Fax Number	:	504-483-6016

Provider Business Practice Location Address
First Line	:	3512 LOUISA ST
Second Line	:	SUITE B
City	:	NEW ORLEANS
State	:	LA
Zip	:	70126-5807
Country	:	US
Telephone Number	:	504-948-2873
Fax Number	:	504-948-9292

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MICHAEL GRIFFIN
Credential	:
Telephone Number	:	504-207-3060

Provider Enumeration Date	:	12/03/2015
Last Update Date	:	12/03/2015

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