1215929211 NPI number — BEACON BEHAVIORAL HEALTH NORTHSHORE INC

Table of content: (NPI 1215929211)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215929211 NPI number — BEACON BEHAVIORAL HEALTH NORTHSHORE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEACON BEHAVIORAL HEALTH NORTHSHORE INC
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:
Provider Other Organization Name Type Code:
6
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:
1215929211
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9938 AIRLINE HWY
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70816-8100
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:
820 ASBURY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANDEVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-727-6090
Provider Business Practice Location Address Fax Number:
985-727-6096
Provider Enumeration Date:
08/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WILDE
Authorized Official First Name:
EARL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHAIRMAN OF THE BOARD
Authorized Official Telephone Number:
225-810-4040

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com