Provider Demographics
NPI:1649725730
Name:GARNER JR., ROSEMORE
Entity type:Individual
Prefix:
First Name:ROSEMORE
Middle Name:
Last Name:GARNER JR.
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 SUMMERLIN DR
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-2672
Mailing Address - Country:US
Mailing Address - Phone:225-315-9905
Mailing Address - Fax:
Practice Address - Street 1:6201 SUMMERLIN DR
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-2672
Practice Address - Country:US
Practice Address - Phone:225-315-9905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA251S00000X343900000X
LA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA251S00000XMedicaid
LA1159204Medicaid