Provider Demographics
NPI:1053648774
Name:WOODLAKE MANAGEMENT, LLC
Entity type:Organization
Organization Name:WOODLAKE MANAGEMENT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-683-4144
Mailing Address - Street 1:3015 HIGHWAY 956
Mailing Address - Street 2:
Mailing Address - City:ETHEL
Mailing Address - State:LA
Mailing Address - Zip Code:70730-4520
Mailing Address - Country:US
Mailing Address - Phone:225-681-4144
Mailing Address - Fax:225-682-4142
Practice Address - Street 1:3015 HIGHWAY 956
Practice Address - Street 2:
Practice Address - City:ETHEL
Practice Address - State:LA
Practice Address - Zip Code:70730-4520
Practice Address - Country:US
Practice Address - Phone:225-681-4144
Practice Address - Fax:225-682-4142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-17
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA156324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility