Provider Demographics
NPI:1679978761
Name:THE SERENITY CENTER OF LOUISIANA, LLC
Entity Type:Organization
Organization Name:THE SERENITY CENTER OF LOUISIANA, LLC
Other - Org Name:SERENITY CLINIC OF LA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALLING SPECIALIST
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 1:2325 WEYMOUTH DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-1481
Mailing Address - Country:US
Mailing Address - Phone:225-361-0899
Mailing Address - Fax:225-367-1421
Practice Address - Street 1:2325 WEYMOUTH DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-1481
Practice Address - Country:US
Practice Address - Phone:225-361-0899
Practice Address - Fax:225-367-1421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-31
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2203782149261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0000000Medicaid