Provider Demographics
NPI:1649844838
Name:NOLA DETOX, LLC
Entity type:Organization
Organization Name:NOLA DETOX, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-975-5552
Mailing Address - Street 1:3221 BEHRMAN PL STE 202A
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70114-8270
Mailing Address - Country:US
Mailing Address - Phone:504-975-5552
Mailing Address - Fax:
Practice Address - Street 1:4201 WOODLAND DR FL 3
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70131-7339
Practice Address - Country:US
Practice Address - Phone:504-975-5552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-13
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility