Healthcare Provider Details

I. General information

NPI: 1962663542
Provider Name (Legal Business Name): VCPHCS V, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 WHITNEY AVENUE BUILDING 4
GRETNA LA
70056
US

IV. Provider business mailing address

5001 SPRING VALLEY ROAD SUITE 600 EAST
DALLAS TX
75244-3946
US

V. Phone/Fax

Practice location:
  • Phone: 504-347-1120
  • Fax:
Mailing address:
  • Phone: 214-365-6100
  • Fax: 214-365-6150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLA10036M
License Number StateLA

VIII. Authorized Official

Name: TONYA ROMERO
Title or Position: DIRECTOR OF PAYOR CREDENTIALING
Credential:
Phone: 208-283-7792