Provider Demographics
NPI:1528182714
Name:G B COOLEY MOORE RD
Entity Type:Organization
Organization Name:G B COOLEY MOORE RD
Other - Org Name:
Other - Org Type:
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 1:612 MOORE RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-7447
Practice Address - Country:US
Practice Address - Phone:318-396-6300
Practice Address - Fax:318-397-9271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA657320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1719072Medicaid