1861074940 NPI number — SPRINGLAKE BEHAVIORAL HEALTH BUNKIE LLC

Table of content: (NPI 1861074940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861074940 NPI number — SPRINGLAKE BEHAVIORAL HEALTH BUNKIE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPRINGLAKE BEHAVIORAL HEALTH BUNKIE 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:
Provider Other Organization Name Type Code:
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:
1861074940
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2021
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:
323 EVERGREEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUNKIE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71322-1307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-346-3143
Provider Business Practice Location Address Fax Number:
318-295-4017
Provider Enumeration Date:
04/27/2021

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: 276400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2700227 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com