Provider Demographics
NPI:1336688878
Name:SANCTUARY LOUISIANA, LLC
Entity Type:Organization
Organization Name:SANCTUARY LOUISIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:TALBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-855-9023
Mailing Address - Street 1:PO BOX 1967
Mailing Address - Street 2:
Mailing Address - City:IOWA
Mailing Address - State:LA
Mailing Address - Zip Code:70647-1967
Mailing Address - Country:US
Mailing Address - Phone:337-855-9023
Mailing Address - Fax:337-588-4179
Practice Address - Street 1:21089 SOUTH FRONTAGE ROAD
Practice Address - Street 2:
Practice Address - City:LACASSINE
Practice Address - State:LA
Practice Address - Zip Code:70650
Practice Address - Country:US
Practice Address - Phone:337-936-9197
Practice Address - Fax:337-588-4179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-16
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA276400000X
324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit