1528182714 NPI number — G B COOLEY MOORE RD

Table of content: (NPI 1528182714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528182714 NPI number — G B COOLEY MOORE RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
G B COOLEY MOORE RD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528182714
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
364 G B COOLEY ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71291-8800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-396-6300
Provider Business Mailing Address Fax Number:
318-396-3660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
612 MOORE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71202-7447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-396-6300
Provider Business Practice Location Address Fax Number:
318-397-9271
Provider Enumeration Date:
03/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PITTS
Authorized Official First Name:
BEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
318-396-6300

Provider Taxonomy Codes

  • Taxonomy code: 320600000X , with the licence number:  657 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1719072 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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