Provider Demographics
NPI:1508856253
Name:OUTPATIENT MEDICAL NUTRITION THERAPY
Entity Type:Organization
Organization Name:OUTPATIENT MEDICAL NUTRITION THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO SR VP
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:HOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-327-7369
Mailing Address - Street 1:PO BOX 1901
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71210-1901
Mailing Address - Country:US
Mailing Address - Phone:318-327-4073
Mailing Address - Fax:318-327-7359
Practice Address - Street 1:920 OLIVER ROAD
Practice Address - Street 2:SUITE 1450
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-7529
Practice Address - Country:US
Practice Address - Phone:318-327-6271
Practice Address - Fax:318-327-5260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA157H261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CH89Medicare ID - Type Unspecified