Provider Demographics
NPI:1275675803
Name:THE MOBILITY DEPOT OF MONROE, LLC
Entity Type:Organization
Organization Name:THE MOBILITY DEPOT OF MONROE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:MENVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-215-2222
Mailing Address - Street 1:7931 ONE CALAIS AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3403
Mailing Address - Country:US
Mailing Address - Phone:225-215-2222
Mailing Address - Fax:225-215-2221
Practice Address - Street 1:1300 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-2710
Practice Address - Country:US
Practice Address - Phone:318-322-2474
Practice Address - Fax:318-322-2479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0600002125332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1131105Medicaid
LA1131105Medicaid