Provider Demographics
NPI:1144660028
Name:RESURRECTION CENTER OF LOUISIANA
Entity type:Organization
Organization Name:RESURRECTION CENTER OF LOUISIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:OMISHA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-455-7275
Mailing Address - Street 1:515 E WASHINGTON ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3658
Mailing Address - Country:US
Mailing Address - Phone:318-455-7275
Mailing Address - Fax:318-658-9134
Practice Address - Street 1:515 E WASHINGTON ST
Practice Address - Street 2:SUITE B
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-3658
Practice Address - Country:US
Practice Address - Phone:318-455-7275
Practice Address - Fax:318-658-9134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LALOUISIANAMedicaid