Healthcare Provider Details

I. General information

NPI: 1154876837
Provider Name (Legal Business Name): G B COOLEY HOSPITAL FOR RETARDED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N 3RD ST
MONROE LA
71201-6731
US

IV. Provider business mailing address

211 N 3RD ST
MONROE LA
71201-6731
US

V. Phone/Fax

Practice location:
  • Phone: 318-397-6679
  • Fax: 318-397-9271
Mailing address:
  • Phone: 318-397-6679
  • Fax: 318-397-9271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. JIMMY SANDERLIN
Title or Position: CFO
Credential: CPA
Phone: 318-397-6679