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General NPI Number Information
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NPI Number | 1982215851
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Entity Type | Organization
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Legal Business Name | SANCTUARY LOUISIANA LLC
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Dates
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Enumeration Date | 08/13/2020
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Last Update Date | 08/29/2023
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Provider Practice Location Address
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Address Line | 21089 SOUTH FRONTAGE ROAD
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City | LACASSINE
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State | LA
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Zip | 70650-9998
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Country | US
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Telephone | 337-936-9197
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Fax | 337-588-4179
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Provider Business Mailing Address
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Address Line | PO BOX 1967
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City | IOWA
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State | LA
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Zip | 70647-1967
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Country | US
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Telephone | 337-936-9197
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | KELVIN SMITH
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Credential |
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Telephone | 337-936-9197
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207RA0401X
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Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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