Provider Demographics
NPI:1891750485
Name:THE MOBILITY DEPOT OF HOUMA, LLC
Entity Type:Organization
Organization Name:THE MOBILITY DEPOT OF HOUMA, LLC
Other - Org Name:MOBILITY DEPOT OF HOUMA
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:MENVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-215-2222
Mailing Address - Street 1:7931 ONE CALAIS AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3403
Mailing Address - Country:US
Mailing Address - Phone:225-215-2222
Mailing Address - Fax:225-215-2248
Practice Address - Street 1:501 BARROW ST
Practice Address - Street 2:SUITE A
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-4605
Practice Address - Country:US
Practice Address - Phone:985-872-4446
Practice Address - Fax:985-872-6325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA602016500OtherUS DEPT OF LABOR
LA690001032OtherBESTCARE
LA690001032OtherOFFICE OF GROUP BENEFITS
LA1122131Medicaid
LA=========0OtherBLUECROSS BLUESHIELD
LA690001032OtherOFFICE OF GROUP BENEFITS