Provider Demographics
NPI:1487137626
Name:BOGALUSA RESTORATION CENTER, LLC
Entity type:Organization
Organization Name:BOGALUSA RESTORATION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF STRATEGIC OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:REILING
Authorized Official - Suffix:
Authorized Official - Credentials:MSS,CP
Authorized Official - Phone:985-241-5340
Mailing Address - Street 1:1640 S COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-5800
Mailing Address - Country:US
Mailing Address - Phone:985-241-5340
Mailing Address - Fax:985-241-5341
Practice Address - Street 1:1640 S COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-5800
Practice Address - Country:US
Practice Address - Phone:985-241-5340
Practice Address - Fax:985-241-5341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-13
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No253J00000XAgenciesFoster Care Agency
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA=========Medicaid