Provider Demographics
NPI:1043780851
Name:LINCOLN NOVA VITAL RECOVERY CENTER,LLC
Entity Type:Organization
Organization Name:LINCOLN NOVA VITAL RECOVERY CENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNY
Authorized Official - Middle Name:E
Authorized Official - Last Name:GAMBLE
Authorized Official - Suffix:JR
Authorized Official - Credentials:FACHCA
Authorized Official - Phone:318-251-4659
Mailing Address - Street 1:8520 BUSINESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5654
Mailing Address - Country:US
Mailing Address - Phone:318-251-4659
Mailing Address - Fax:318-251-4659
Practice Address - Street 1:4396 HIGHWAY 80
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-8948
Practice Address - Country:US
Practice Address - Phone:318-251-4659
Practice Address - Fax:318-251-4659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-05
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1336348317Other251S00000X