Healthcare Provider Details

I. General information

NPI: 1013732940
Provider Name (Legal Business Name): BROWN SUGAR HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2024
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 BROMPTON LN
BOSSIER CITY LA
71111-8208
US

IV. Provider business mailing address

507 BROMPTON LN
BOSSIER CITY LA
71111-8208
US

V. Phone/Fax

Practice location:
  • Phone: 818-515-7991
  • Fax:
Mailing address:
  • Phone: 818-515-7991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DERRICK WAYNE SMITH
Title or Position: CEO
Credential: MD
Phone: 818-515-7991