1114550001 NPI number — BEACON BEHAVIORAL HOSPITAL LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114550001 NPI number — BEACON BEHAVIORAL HOSPITAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEACON BEHAVIORAL HOSPITAL LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BEACON BEHAVIORAL OUTPATIENT - HAMMOND
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114550001
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4601 BLUEBONNET BLVD STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70809-9656
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-810-4040
Provider Business Mailing Address Fax Number:
225-810-4050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
42382 DELUXE PLZ STE 34
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMMOND
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70403-1236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-956-7378
Provider Business Practice Location Address Fax Number:
985-956-7381
Provider Enumeration Date:
02/19/2020

Additional Information

Authorized Official

Authorized Official Last Name:
WENDELL
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
SEAN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
225-810-4040

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 194102 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2184164 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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