Basic Information
| Provider Information | |||||||||
| NPI: | 1932278140 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OCEANS BEHAVIORAL HOSPITAL OF DERIDDER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3905 HEDGCOXE RD UNIT 250249 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750250840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724640022 | ||||||||
| FaxNumber: | 9724640021 | ||||||||
| Practice Location | |||||||||
| Address1: | 1420 BLANKENSHIP DRIVE | ||||||||
| Address2: | |||||||||
| City: | DERIDDER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374609472 | ||||||||
| FaxNumber: | 3374609473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 01/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | ARCHER | ||||||||
| AuthorizedOfficialFirstName: | STUART | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9724640022 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | 580 | LA | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 191013501 | 05 | TX | MEDICAID | DHHLICENSE 580 | 01 | DHH LICENSE | OTHER | 1523879 | 05 | LA | MEDICAID |