Healthcare Provider Details

I. General information

NPI: 1215003827
Provider Name (Legal Business Name): CDP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68445 TAMMANY TRACE DR
MANDEVILLE LA
70471-7779
US

IV. Provider business mailing address

68445 TAMMANY TRACE DR
MANDEVILLE LA
70471-7779
US

V. Phone/Fax

Practice location:
  • Phone: 985-647-5175
  • Fax: 985-674-5177
Mailing address:
  • Phone: 985-647-5175
  • Fax: 985-674-5177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number1013
License Number StateLA

VIII. Authorized Official

Name: MR. DWAYNE T GOFF
Title or Position: OWNER
Credential:
Phone: 985-674-5175