Provider Demographics
NPI:1164828190
Name:DDMS OF LOUISIANA NO 2, LLC
Entity Type:Organization
Organization Name:DDMS OF LOUISIANA NO 2, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:IAN
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-388-5150
Mailing Address - Street 1:313 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02210-1218
Mailing Address - Country:US
Mailing Address - Phone:800-388-5150
Mailing Address - Fax:617-790-4271
Practice Address - Street 1:3235 IDAHO AVE
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-4524
Practice Address - Country:US
Practice Address - Phone:504-712-1323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-19
Last Update Date:2023-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAAPPLIED FORMedicaid