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General NPI Number Information
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NPI Number | 1245468826
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Entity Type | Organization
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Legal Business Name | EDGEFIELD RECOVERY CENTER, LLC
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Dates
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Enumeration Date | 06/23/2009
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Last Update Date | 06/23/2009
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Provider Practice Location Address
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Address Line | 10631 HWY 71 SOUTH
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City | CHENEYVILLE
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State | LA
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Zip | 71325
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Country | US
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Telephone | 318-279-2751
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Fax | 318-279-2755
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Provider Business Mailing Address
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Address Line | PO BOX 407
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City | CHENEYVILLE
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State | LA
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Zip | 71325-0407
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Country | US
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Telephone | 318-279-2751
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Fax | 318-279-2755
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Authorized Official
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Title or Position | COO
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Name | MR. TOM BRENNAN
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Credential |
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Telephone | 318-279-2751
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 448
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License Number State | LA
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