Healthcare Provider Details

I. General information

NPI: 1336906478
Provider Name (Legal Business Name): RED STICK RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2024
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

856 HIGHWAY 90 STE D
BAY ST LOUIS MS
39520-2737
US

IV. Provider business mailing address

6720 GREENMEADOW DR
GREENWELL SPRINGS LA
70739-4102
US

V. Phone/Fax

Practice location:
  • Phone: 228-215-0255
  • Fax: 228-215-0255
Mailing address:
  • Phone: 225-978-4264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. KALEY BENSON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: RN
Phone: 228-215-0255