Provider Demographics
NPI:1831779107
Name:GEORGIA TUCKER LLC
Entity type:Organization
Organization Name:GEORGIA TUCKER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:COBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-789-2001
Mailing Address - Street 1:414 PINE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-6228
Mailing Address - Country:US
Mailing Address - Phone:318-699-8819
Mailing Address - Fax:
Practice Address - Street 1:405 STUBBS AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5505
Practice Address - Country:US
Practice Address - Phone:318-538-0040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1709581Medicaid