1578574471 NPI number — CYPRESS GROVE BEHAVIORAL HEALTH LLC

Table of content: (NPI 1578574471)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578574471 NPI number — CYPRESS GROVE BEHAVIORAL HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CYPRESS GROVE BEHAVIORAL HEALTH 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:
MERIDIAN BEHAVIORAL HEALTH
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:
1578574471
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 MAIN STREET
Provider Second Line Business Mailing Address:
SUITE 250, CONTRACTING/CREDENTIALING
Provider Business Mailing Address City Name:
NEW BRIGHTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-326-7575
Provider Business Mailing Address Fax Number:
612-454-2430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
414 PINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71201-6228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-699-8819
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF ADMINISTRATIVE OFFICER
Authorized Official Telephone Number:
612-326-7575

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 159664125 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1709581 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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