Healthcare Provider Details

I. General information

NPI: 1669428140
Provider Name (Legal Business Name): MMO OF COVINGTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 GREENBRIAR BLVD
COVINGTON LA
70433-7236
US

IV. Provider business mailing address

728 NORTH BLVD
BATON ROUGE LA
70802-5724
US

V. Phone/Fax

Practice location:
  • Phone: 985-249-7780
  • Fax: 985-249-7782
Mailing address:
  • Phone: 225-293-6774
  • Fax: 225-291-9229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number194701
License Number StateLA

VIII. Authorized Official

Name: MR. ROBERT L. MILLER
Title or Position: EXECUTIVE OFFICER
Credential:
Phone: 225-293-6774