1063638831 NPI number — NORTHLAKE PRIMARY CARE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063638831 NPI number — NORTHLAKE PRIMARY CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHLAKE PRIMARY CARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063638831
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
951 GAUSE BLVD STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SLIDELL
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70458-2937
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-641-6454
Provider Business Mailing Address Fax Number:
985-641-6458

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
951 GAUSE BLVD STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SLIDELL
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70458-2937
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-641-6454
Provider Business Practice Location Address Fax Number:
985-641-6458
Provider Enumeration Date:
04/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LEFRAN
Authorized Official First Name:
JOSE
Authorized Official Middle Name:
ANTONIO
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
985-641-6454

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MD11789R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 14557 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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