Provider Demographics
NPI:1982003398
Name:BRIGHTSIDE DAY HABILITATION
Entity Type:Organization
Organization Name:BRIGHTSIDE DAY HABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LIZABETH
Authorized Official - Middle Name:DELL
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-615-7018
Mailing Address - Street 1:557 E MAIN ST
Mailing Address - Street 2:A
Mailing Address - City:BRUSLY
Mailing Address - State:LA
Mailing Address - Zip Code:70719-2210
Mailing Address - Country:US
Mailing Address - Phone:225-615-7018
Mailing Address - Fax:225-615-7492
Practice Address - Street 1:557 E MAIN ST
Practice Address - Street 2:A
Practice Address - City:BRUSLY
Practice Address - State:LA
Practice Address - Zip Code:70719-2210
Practice Address - Country:US
Practice Address - Phone:225-615-7018
Practice Address - Fax:225-615-7492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2203781925251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAHC0011192Medicaid