Provider Demographics
NPI:1912473752
Name:LINCOLN NOVA VITAL RECOVERY
Entity Type:Organization
Organization Name:LINCOLN NOVA VITAL RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEWEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:MAY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, SACN
Authorized Official - Phone:318-235-0503
Mailing Address - Street 1:203 BRIAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291
Mailing Address - Country:US
Mailing Address - Phone:318-235-0503
Mailing Address - Fax:318-251-4659
Practice Address - Street 1:4396 HWY, 80
Practice Address - Street 2:617 SOUTH TRENTION
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270
Practice Address - Country:US
Practice Address - Phone:318-235-0503
Practice Address - Fax:318-251-4659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-19
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty