Provider Demographics
NPI:1972110401
Name:DR. GLENN M COULLARD
Entity Type:Organization
Organization Name:DR. GLENN M COULLARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LOEBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-324-5190
Mailing Address - Street 1:156 GOLDEN MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-6604
Mailing Address - Country:US
Mailing Address - Phone:225-938-7701
Mailing Address - Fax:225-658-2424
Practice Address - Street 1:11937 FERDINAND STREET
Practice Address - Street 2:
Practice Address - City:SAINT FRANCISVILLE
Practice Address - State:LA
Practice Address - Zip Code:70775-4342
Practice Address - Country:US
Practice Address - Phone:225-635-6483
Practice Address - Fax:225-658-2424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty