MEDICARE: GREATER NEW ORLEANS TEEN CHALLENGE INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1326570458
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREATER NEW ORLEANS TEEN CHALLENGE INC.

Provider Business Mailing Address
First Line	:	1905 FRANKLIN AVE
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70117-7603
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1905 FRANKLIN AVE
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70117-7603
Country	:	US
Telephone Number	:	504-947-4443
Fax Number	:

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MR. GARY BENTLEY
Credential	:
Telephone Number	:	504-481-5499

Provider Enumeration Date	:	03/29/2017
Last Update Date	:	03/29/2017

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