Healthcare Provider Details

I. General information

NPI: 1043780851
Provider Name (Legal Business Name): LINCOLN NOVA VITAL RECOVERY CENTER,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4396 HIGHWAY 80
RUSTON LA
71270-8948
US

IV. Provider business mailing address

8520 BUSINESS PARK DR
SHREVEPORT LA
71105-5654
US

V. Phone/Fax

Practice location:
  • Phone: 318-251-4659
  • Fax: 318-251-4659
Mailing address:
  • Phone: 318-251-4659
  • Fax: 318-251-4659

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: MR. DENNY E. GAMBLE JR.
Title or Position: OWNER
Credential: FACHCA
Phone: 318-251-4659