Provider Demographics
NPI:1184044430
Name:SPRINGLAKE BEHAVIORAL HEALTH BUNKIE LLC
Entity Type:Organization
Organization Name:SPRINGLAKE BEHAVIORAL HEALTH BUNKIE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:SEAN
Authorized Official - Last Name:WENDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-810-4050
Mailing Address - Street 1:14707 PERKINS RD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-2216
Mailing Address - Country:US
Mailing Address - Phone:225-810-4040
Mailing Address - Fax:225-810-4050
Practice Address - Street 1:323 EVERGREEN ST STE B
Practice Address - Street 2:
Practice Address - City:BUNKIE
Practice Address - State:LA
Practice Address - Zip Code:71322-1307
Practice Address - Country:US
Practice Address - Phone:318-346-3143
Practice Address - Fax:318-295-4017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-24
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X, 276400000X
LA283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2700227Medicaid
194112OtherMEDICARE