Provider Demographics
NPI:1437285442
Name:THE WILL OF GOD MINISTRIES OUTREACH PROGRAM
Entity Type:Organization
Organization Name:THE WILL OF GOD MINISTRIES OUTREACH PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-932-3177
Mailing Address - Street 1:1113 CALIOPE STREET
Mailing Address - Street 2:
Mailing Address - City:COUSHATTA
Mailing Address - State:LA
Mailing Address - Zip Code:71019
Mailing Address - Country:US
Mailing Address - Phone:318-932-3177
Mailing Address - Fax:
Practice Address - Street 1:1113 CALIOPE STREET
Practice Address - Street 2:
Practice Address - City:COUSHATTA
Practice Address - State:LA
Practice Address - Zip Code:71019
Practice Address - Country:US
Practice Address - Phone:318-932-3177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10793305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1470694Medicaid