Provider Demographics
NPI:1013732940
Name:BROWN SUGAR HEALTH LLC
Entity type:Organization
Organization Name:BROWN SUGAR HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-515-7991
Mailing Address - Street 1:507 BROMPTON LN
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-8208
Mailing Address - Country:US
Mailing Address - Phone:818-515-7991
Mailing Address - Fax:
Practice Address - Street 1:7500 BANNER WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-4176
Practice Address - Country:US
Practice Address - Phone:318-642-4909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No251S00000XAgenciesCommunity/Behavioral Health