Provider Demographics
NPI:1982215851
Name:SANCTUARY LOUISIANA LLC
Entity Type:Organization
Organization Name:SANCTUARY LOUISIANA LLC
Other - Org Name:SANCTUARY OF LOUISIANA CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-936-9197
Mailing Address - Street 1:PO BOX 1967
Mailing Address - Street 2:
Mailing Address - City:IOWA
Mailing Address - State:LA
Mailing Address - Zip Code:70647-1967
Mailing Address - Country:US
Mailing Address - Phone:337-936-9197
Mailing Address - Fax:
Practice Address - Street 1:21089 SOUTH FRONTAGE ROAD
Practice Address - Street 2:
Practice Address - City:LACASSINE
Practice Address - State:LA
Practice Address - Zip Code:70650-9998
Practice Address - Country:US
Practice Address - Phone:337-936-9197
Practice Address - Fax:337-588-4179
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SANCTUARY LOUISIANA LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-13
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty