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General NPI Number Information
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NPI Number | 1376157032
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Entity Type | Organization
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Legal Business Name | WOODLAKE ADDICTION RECOVERY OF MISSISSIPPI, LLC
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Dates
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Enumeration Date | 09/01/2020
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Last Update Date | 09/01/2020
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Provider Practice Location Address
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Address Line | 152 GATEWAY DR
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City | BILOXI
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State | MS
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Zip | 39531-4409
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Country | US
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Telephone | 225-924-1910
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 41853
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City | BATON ROUGE
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State | LA
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Zip | 70835-1853
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Country | US
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Telephone | 225-900-8940
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Fax | 855-532-9362
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | KENDALL MCCULLAR
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Credential |
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Telephone | 225-900-8940
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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 |
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License Number State |
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