1154067155 NPI number — WELLNESS INSTITUTE OF NEPHROLOGY, LLC (WIN)

Table of content: (NPI 1154067155)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154067155 NPI number — WELLNESS INSTITUTE OF NEPHROLOGY, LLC (WIN)

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLNESS INSTITUTE OF NEPHROLOGY, LLC (WIN)
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:
1154067155
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26 PLATT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNER
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70065-1065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-939-3640
Provider Business Mailing Address Fax Number:
504-469-7138

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 W ESPLANADE AVE STE 305
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNER
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70065-2474
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-464-8712
Provider Business Practice Location Address Fax Number:
504-464-8711
Provider Enumeration Date:
05/11/2022

Additional Information

Authorized Official

Authorized Official Last Name:
MORSE
Authorized Official First Name:
MALIKA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
504-939-3640

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1577464 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4J284 . This is a "MEDICARE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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