Provider Demographics
NPI:1093883522
Name:MMO OF GONZALES, LLC
Entity Type:Organization
Organization Name:MMO OF GONZALES, LLC
Other - Org Name:ON TRACK COMMUNITY HEALTH CENTER LLC DBASILVER OPTIONS CENTER ON-TRACK
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-293-6774
Mailing Address - Street 1:728 NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70802-5724
Mailing Address - Country:US
Mailing Address - Phone:225-621-2760
Mailing Address - Fax:225-621-2768
Practice Address - Street 1:305 SOUTH BURNSIDE AVE.
Practice Address - Street 2:SUITE D
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737
Practice Address - Country:US
Practice Address - Phone:225-621-2760
Practice Address - Fax:225-621-2768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA531032261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA19-4614Medicare ID - Type Unspecified