Provider Demographics
NPI:1568684645
Name:CALDWELL COUNCIL ON AGING
Entity Type:Organization
Organization Name:CALDWELL COUNCIL ON AGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DOTTIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:ETHERIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-649-2584
Mailing Address - Street 1:307 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:LA
Mailing Address - Zip Code:71418-1498
Mailing Address - Country:US
Mailing Address - Phone:318-649-2584
Mailing Address - Fax:318-649-7600
Practice Address - Street 1:307 MAIN STREET
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:LA
Practice Address - Zip Code:71418-1498
Practice Address - Country:US
Practice Address - Phone:318-649-2584
Practice Address - Fax:318-649-7600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACM2302251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1548189Medicaid