1164422630 NPI number — CONVENIENT CARE LLC

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 1164422630 NPI number — CONVENIENT CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONVENIENT CARE LLC
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:
LAKE AFTER HOURS PERKINS
Provider Other Organization Name Type Code:
3
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:
1164422630
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 679632
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75267-9632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12525 PERKINS RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70810-1907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-819-8857
Provider Business Practice Location Address Fax Number:
225-767-6822
Provider Enumeration Date:
07/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SELLARS
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
COO/PRESIDENT
Authorized Official Telephone Number:
225-214-9353

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CJ4680 . This is a "RAILROAD" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1441376 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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