Basic Information
| Provider Information | |||||||||
| NPI: | 1912473752 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LINCOLN NOVA VITAL RECOVERY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 203 BRIAN DRIVE | ||||||||
| Address2: | |||||||||
| City: | WEST MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182350503 | ||||||||
| FaxNumber: | 3182514659 | ||||||||
| Practice Location | |||||||||
| Address1: | 4396 HWY, 80 | ||||||||
| Address2: | 617 SOUTH TRENTION | ||||||||
| City: | RUSTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182350503 | ||||||||
| FaxNumber: | 3182514659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2018 | ||||||||
| LastUpdateDate: | 10/19/2018 | ||||||||
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| AuthorizedOfficialLastName: | MAY | ||||||||
| AuthorizedOfficialFirstName: | JEWEL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3182350503 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MA, SACN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.