1225119225 NPI number — CONVENIENT CARE LLC

Table of content: (NPI 1225119225)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225119225 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 HAMMOND
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:
1225119225
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:
42205 VETERANS AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMMOND
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-375-9979
Provider Business Practice Location Address Fax Number:
985-375-9978
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SELLARS
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
COO/PRESIDENT
Authorized Official Telephone Number:
225-214-9352

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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