Provider Demographics
NPI:1235263468
Name:G B COOLEY HOSPITAL SERVICE DISTRICT
Entity Type:Organization
Organization Name:G B COOLEY HOSPITAL SERVICE DISTRICT
Other - Org Name:G B COOLEY SERVICES-CAMPUS
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PITTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-396-6300
Mailing Address - Street 1:364 G B COOLEY ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-8800
Mailing Address - Country:US
Mailing Address - Phone:318-396-6300
Mailing Address - Fax:318-396-3660
Practice Address - Street 1:364 G B COOLEY ROAD
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-8800
Practice Address - Country:US
Practice Address - Phone:318-396-6300
Practice Address - Fax:318-396-3660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
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
LA1715042Medicaid