Provider Demographics
NPI:1982901104
Name:GULF COAST OPPORTUNITY CENTER, INC.
Entity Type:Organization
Organization Name:GULF COAST OPPORTUNITY CENTER, INC.
Other - Org Name:LAFAYETTE SENIOR CLUB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOAD MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCPHERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-445-6470
Mailing Address - Street 1:4333 SHREVEPORT HWY
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-3828
Mailing Address - Country:US
Mailing Address - Phone:318-445-6470
Mailing Address - Fax:
Practice Address - Street 1:1011 SURREY ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-6142
Practice Address - Country:US
Practice Address - Phone:337-654-5519
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-24
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2121936Medicaid