Provider Demographics
NPI:1538375753
Name:UNIVERSITY OF LOUISIANA MONROE
Entity type:Organization
Organization Name:UNIVERSITY OF LOUISIANA MONROE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:WOOTEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD
Authorized Official - Phone:318-361-3003
Mailing Address - Street 1:4606 LINCLON PRK AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5919
Mailing Address - Country:US
Mailing Address - Phone:318-324-9450
Mailing Address - Fax:318-324-9450
Practice Address - Street 1:4604 LINCOLN PARK AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-5919
Practice Address - Country:US
Practice Address - Phone:318-324-9450
Practice Address - Fax:318-324-9450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA120530302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization