Provider Demographics
NPI:1942033808
Name:PEACOCK ADDICTION TREATMENT & HEALING (PATH) CENTER LLC
Entity type:Organization
Organization Name:PEACOCK ADDICTION TREATMENT & HEALING (PATH) CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JO
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:318-334-5825
Mailing Address - Street 1:437 OVERLAN STAGE RD
Mailing Address - Street 2:
Mailing Address - City:RAYVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71269-7655
Mailing Address - Country:US
Mailing Address - Phone:318-334-5825
Mailing Address - Fax:318-301-6826
Practice Address - Street 1:1401 LOUISA ST
Practice Address - Street 2:
Practice Address - City:RAYVILLE
Practice Address - State:LA
Practice Address - Zip Code:71269-3245
Practice Address - Country:US
Practice Address - Phone:318-303-4632
Practice Address - Fax:318-301-6826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-24
Last Update Date:2024-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center