Basic Information
| Provider Information | |||||||||
| NPI: | 1366820706 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PECAN HAVEN ADDICTION RECOVERY CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PECAN HAVEN ADOLESCENT ADDICTION CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2321 HWY 80 EAST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186003333 | ||||||||
| FaxNumber: | 3186003334 | ||||||||
| Practice Location | |||||||||
| Address1: | 2321 HWY 80 EAST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186003333 | ||||||||
| FaxNumber: | 3186003334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2015 | ||||||||
| LastUpdateDate: | 09/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | FONTENOT | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | PEELER | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3186003333 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 220382709 | LA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.