Healthcare Provider Details

I. General information

NPI: 1487137626
Provider Name (Legal Business Name): BOGALUSA RESTORATION CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2018
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 S COLUMBIA ST
BOGALUSA LA
70427-5800
US

IV. Provider business mailing address

1640 S COLUMBIA ST
BOGALUSA LA
70427-5800
US

V. Phone/Fax

Practice location:
  • Phone: 985-241-5340
  • Fax: 985-241-5341
Mailing address:
  • Phone: 985-241-5340
  • Fax: 985-241-5341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. JENNIFER REILING
Title or Position: CHIEF STRATEGIC OFFICER
Credential: MSS,CP
Phone: 985-241-5340