Provider Demographics
NPI:1477973857
Name:LILITH OF NATCHITOCHES
Entity Type:Organization
Organization Name:LILITH OF NATCHITOCHES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:AMONS
Authorized Official - Suffix:JR
Authorized Official - Credentials:BSN, MSA
Authorized Official - Phone:318-229-1175
Mailing Address - Street 1:103 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-7839
Mailing Address - Country:US
Mailing Address - Phone:318-229-1175
Mailing Address - Fax:
Practice Address - Street 1:103 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-7839
Practice Address - Country:US
Practice Address - Phone:318-229-1175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1857108-001324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility