Provider Demographics
NPI:1336471796
Name:FAMILY NEW LIFE BASTROP LLC
Entity Type:Organization
Organization Name:FAMILY NEW LIFE BASTROP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ADRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-325-8050
Mailing Address - Street 1:1705 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 MCCREIGHT ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-3955
Practice Address - Country:US
Practice Address - Phone:318-556-4081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-09
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health