Provider Demographics
NPI:1124380621
Name:CITY OF DERIDDER
Entity Type:Organization
Organization Name:CITY OF DERIDDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MAYOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-462-8900
Mailing Address - Street 1:200 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-5089
Mailing Address - Country:US
Mailing Address - Phone:337-462-8900
Mailing Address - Fax:337-462-8908
Practice Address - Street 1:200 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-5089
Practice Address - Country:US
Practice Address - Phone:337-462-8900
Practice Address - Fax:337-462-8908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2179764343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2179764Medicaid