Provider Demographics
NPI:1902274525
Name:SEASIDE BEHAVIORAL CENTER, LLC
Entity Type:Organization
Organization Name:SEASIDE BEHAVIORAL CENTER, LLC
Other - Org Name:SBC PHYSICIAN GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LANCASTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-841-2619
Mailing Address - Street 1:101 FEU FOLLET DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503
Mailing Address - Country:US
Mailing Address - Phone:337-234-8455
Mailing Address - Fax:337-234-8482
Practice Address - Street 1:4201 WOODLAND DRIVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70131
Practice Address - Country:US
Practice Address - Phone:504-393-4223
Practice Address - Fax:504-267-5692
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SEASIDE BEHAVIORAL CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA22037817252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2700073Medicaid
LA2700073Medicaid