Provider Demographics
NPI:1659410611
Name:LASALLE ASSOCIATION FOR THE DEVELOPMENTALLY DELAYED, INC
Entity Type:Organization
Organization Name:LASALLE ASSOCIATION FOR THE DEVELOPMENTALLY DELAYED, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRANSPORATION COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:B
Authorized Official - Last Name:COON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-992-6217
Mailing Address - Street 1:1258 PEPPER ST
Mailing Address - Street 2:
Mailing Address - City:JENA
Mailing Address - State:LA
Mailing Address - Zip Code:71342-4432
Mailing Address - Country:US
Mailing Address - Phone:318-992-6217
Mailing Address - Fax:318-992-0467
Practice Address - Street 1:1258 PEPPER ST
Practice Address - Street 2:
Practice Address - City:JENA
Practice Address - State:LA
Practice Address - Zip Code:71342-4432
Practice Address - Country:US
Practice Address - Phone:318-992-6217
Practice Address - Fax:318-992-0467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAADC2324302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1936189Medicaid