Healthcare Provider Details

I. General information

NPI: 1558203190
Provider Name (Legal Business Name): NOVA VITAL NATCHITOCHES RECOVERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2026
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 KEYSER AVE
NATCHITOCHES LA
71457-6043
US

IV. Provider business mailing address

8520 BUSINESS PARK DR
SHREVEPORT LA
71105-5654
US

V. Phone/Fax

Practice location:
  • Phone: 318-228-1959
  • Fax:
Mailing address:
  • Phone: 318-228-1959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DENNY GAMBLE JR.
Title or Position: OWNER/MANAGING MEMBER
Credential:
Phone: 318-458-6254