1114051653 NPI number — NORTHSTAR NEUROLOGY 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 1114051653 NPI number — NORTHSTAR NEUROLOGY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHSTAR NEUROLOGY 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:
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:
1114051653
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 81082
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70598-1082
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-233-3850
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
516 VEROT SCHOOL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70508-5026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-233-3850
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DEALVARE
Authorized Official First Name:
LEOPOLDO
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
337-233-3850

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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