Provider Demographics
NPI:1780191486
Name:EASY LIVING BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:EASY LIVING BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-376-0729
Mailing Address - Street 1:1109 CARTER ST STE 8
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-3227
Mailing Address - Country:US
Mailing Address - Phone:318-734-0034
Mailing Address - Fax:318-734-0035
Practice Address - Street 1:1109 CARTER ST STE 8
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-3227
Practice Address - Country:US
Practice Address - Phone:318-734-0034
Practice Address - Fax:318-734-0035
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASY LIVING HOME CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5782381Medicaid