Provider Demographics
NPI:1366820706
Name:PECAN HAVEN ADDICTION RECOVERY CENTER, LLC
Entity Type:Organization
Organization Name:PECAN HAVEN ADDICTION RECOVERY CENTER, LLC
Other - Org Name:PECAN HAVEN ADOLESCENT ADDICTION CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:PEELER
Authorized Official - Last Name:FONTENOT
Authorized Official - Suffix:
Authorized Official - Credentials:CPPM
Authorized Official - Phone:318-600-3333
Mailing Address - Street 1:2321 HWY 80 EAST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203
Mailing Address - Country:US
Mailing Address - Phone:318-600-3333
Mailing Address - Fax:318-600-3334
Practice Address - Street 1:2321 HWY 80 EAST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203
Practice Address - Country:US
Practice Address - Phone:318-600-3333
Practice Address - Fax:318-600-3334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-18
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA220382709324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility