Provider Demographics
NPI:1336906478
Name:RED STICK RECOVERY LLC
Entity Type:Organization
Organization Name:RED STICK RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KALEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:228-215-0255
Mailing Address - Street 1:6720 GREENMEADOW DR
Mailing Address - Street 2:
Mailing Address - City:GREENWELL SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70739-4102
Mailing Address - Country:US
Mailing Address - Phone:225-978-4264
Mailing Address - Fax:
Practice Address - Street 1:856 HIGHWAY 90 STE D
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-2737
Practice Address - Country:US
Practice Address - Phone:228-215-0255
Practice Address - Fax:228-215-0255
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RED STICK RECOVERY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty