Healthcare Provider Details

I. General information

NPI: 1659410611
Provider Name (Legal Business Name): LASALLE ASSOCIATION FOR THE DEVELOPMENTALLY DELAYED, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1258 PEPPER ST
JENA LA
71342-4432
US

IV. Provider business mailing address

1258 PEPPER ST
JENA LA
71342-4432
US

V. Phone/Fax

Practice location:
  • Phone: 318-992-6217
  • Fax: 318-992-0467
Mailing address:
  • Phone: 318-992-6217
  • Fax: 318-992-0467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberADC2324
License Number StateLA

VIII. Authorized Official

Name: MRS. PAMELA B. COON
Title or Position: TRANSPORATION COORDINATOR
Credential:
Phone: 318-992-6217