=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013732940
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROWN SUGAR HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2024
-----------------------------------------------------
Last Update Date | 11/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7500 BANNER WAY NE
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98115-4176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-642-4909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 507 BROMPTON LN
-----------------------------------------------------
City | BOSSIER CITY
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71111-8208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-515-7991
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. DERRICK WAYNE SMITH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 818-515-7991
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------