Healthcare Provider Details

I. General information

NPI: 1942033808
Provider Name (Legal Business Name): PEACOCK ADDICTION TREATMENT & HEALING (PATH) CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2024
Last Update Date: 08/24/2024
Certification Date: 08/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 LOUISA ST
RAYVILLE LA
71269-3245
US

IV. Provider business mailing address

437 OVERLAN STAGE RD
RAYVILLE LA
71269-7655
US

V. Phone/Fax

Practice location:
  • Phone: 318-303-4632
  • Fax: 318-301-6826
Mailing address:
  • Phone: 318-334-5825
  • Fax: 318-301-6826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. JO LYNN BENNETT
Title or Position: OWNER
Credential: APRN
Phone: 318-334-5825