Healthcare Provider Details

I. General information

NPI: 1821248279
Provider Name (Legal Business Name): ALTERNATIVES FOR LIFE TREATMENT & RECOVERY OF JACKSON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5360 I 55 N STE 160
JACKSON MS
39211-4055
US

IV. Provider business mailing address

PO BOX 2344
MANDEVILLE LA
70470-2344
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-3131
  • Fax: 601-362-3339
Mailing address:
  • Phone: 504-812-6431
  • Fax: 601-362-3339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberMS-10003-M
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State

VIII. Authorized Official

Name: MR. RUEBEN S BIENVENU
Title or Position: PROGRAM SPONSOR
Credential:
Phone: 337-298-1257