Healthcare Provider Details

I. General information

NPI: 1356055131
Provider Name (Legal Business Name): BHG LXXIX, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2023
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 BEACH STREET OBOT ROOM #100
WESTERLY RI
02891
US

IV. Provider business mailing address

5001 SPRING VALLEY RD STE 600
DALLAS TX
75244-3946
US

V. Phone/Fax

Practice location:
  • Phone: 401-596-0969
  • Fax: 401-348-0265
Mailing address:
  • Phone: 214-365-6100
  • Fax: 214-365-6150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL

VIII. Authorized Official

Name: JAY HIGHAM
Title or Position: CEO
Credential:
Phone: 214-365-6112