Provider Demographics
NPI:1770739906
Name:DESOTO COUNCIL ON AGING, INC.
Entity type:Organization
Organization Name:DESOTO COUNCIL ON AGING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-872-2691
Mailing Address - Street 1:1015 POLK ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71052-2522
Mailing Address - Country:US
Mailing Address - Phone:318-872-2691
Mailing Address - Fax:318-872-9473
Practice Address - Street 1:1015 POLK ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:LA
Practice Address - Zip Code:71052-2522
Practice Address - Country:US
Practice Address - Phone:318-872-2691
Practice Address - Fax:318-872-9473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15058251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1964352Medicaid
LA1393444Medicaid
LA1461229Medicaid