Provider Demographics
NPI:1215003827
Name:CDP, LLC
Entity Type:Organization
Organization Name:CDP, LLC
Other - Org Name:OMNI HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:T
Authorized Official - Last Name:GOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-674-5175
Mailing Address - Street 1:68445 TAMMANY TRACE DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-7779
Mailing Address - Country:US
Mailing Address - Phone:985-647-5175
Mailing Address - Fax:985-674-5177
Practice Address - Street 1:68445 TAMMANY TRACE DR
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-7779
Practice Address - Country:US
Practice Address - Phone:985-647-5175
Practice Address - Fax:985-674-5177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1013251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1400971Medicaid
LA1400971Medicaid