Provider Demographics
NPI:1306875398
Name:MAMOU HEALTH RESOURCES, INC.
Entity type:Organization
Organization Name:MAMOU HEALTH RESOURCES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, BOARD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:FONTENOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-468-5959
Mailing Address - Street 1:300 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:MAMOU
Mailing Address - State:LA
Mailing Address - Zip Code:70554-4422
Mailing Address - Country:US
Mailing Address - Phone:337-468-5959
Mailing Address - Fax:337-468-5966
Practice Address - Street 1:1510 NAPOLEON ST
Practice Address - Street 2:
Practice Address - City:MAMOU
Practice Address - State:LA
Practice Address - Zip Code:70554-2320
Practice Address - Country:US
Practice Address - Phone:337-468-2333
Practice Address - Fax:337-468-3620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1122785Medicaid
LA1122785Medicaid