Provider Demographics
NPI:1881866044
Name:ANN B TUBRE, LOTR
Entity Type:Organization
Organization Name:ANN B TUBRE, LOTR
Other - Org Name:ANN B TUBRE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-366-9680
Mailing Address - Street 1:226 CALDWELL RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-1627
Mailing Address - Country:US
Mailing Address - Phone:318-235-4541
Mailing Address - Fax:318-410-4351
Practice Address - Street 1:226 CALDWELL RD
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-1627
Practice Address - Country:US
Practice Address - Phone:318-235-4541
Practice Address - Fax:318-410-4351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ10523174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1199401Medicaid