Provider Demographics
NPI:1437281664
Name:G B COOLEY SERVICES SHANNON
Entity Type:Organization
Organization Name:G B COOLEY SERVICES SHANNON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
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 GB COOLEY RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-8866
Mailing Address - Country:US
Mailing Address - Phone:318-396-6300
Mailing Address - Fax:318-396-3660
Practice Address - Street 1:1591 SHANNON ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-4958
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:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA379320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1716375Medicaid