Healthcare Provider Details

I. General information

NPI: 1174736409
Provider Name (Legal Business Name): RED RIVER COUNCIL ON AGING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 FRONT STREET
COUSHATTA LA
71019
US

IV. Provider business mailing address

P.O. DRAWER 688
COUSHATTA LA
71019
US

V. Phone/Fax

Practice location:
  • Phone: 318-932-5721
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number2668
License Number StateLA

VIII. Authorized Official

Name: MS. MARY WAILES
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 318-932-5721