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Active
Organization subpart
No

Provider details

NPI number
Authorized official
CATHY WILLIS (MANAGER)
(318) 775-9420
Entity
Organization

Contact information

Practice address
250 COUNTRY CLUB BLVD, MONROE, LA 71202-7302
(318) 775-9420
Mailing address
PO BOX 13124, MONROE, LA 71213-3124
(318) 775-9420

Taxonomy

Speciality
Code
Description
License number
State
347C00000X
Private Vehicle
Primary
LA

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
347C00000X
LA
Enumeration date
04/10/2017
Last updated
04/10/2017
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