1497090740 NPI number — OLOL PONTCHARTRAIN SURGERY CENTER, LLC

Table of content: (NPI 1497090740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497090740 NPI number — OLOL PONTCHARTRAIN SURGERY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OLOL PONTCHARTRAIN SURGERY CENTER, 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:
OUR LADY OF THE LAKE PONTCHARTRAIN SURGERY CENTER
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:
1497090740
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4407 HIGHWAY 190 EAST SERVICE RD
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
COVINGTON
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70433-4957
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-234-9700
Provider Business Mailing Address Fax Number:
985-234-9706

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4407 HIGHWAY 190 EAST SERVICE RD
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70433-4957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-234-9700
Provider Business Practice Location Address Fax Number:
985-234-9706
Provider Enumeration Date:
11/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MORAN
Authorized Official First Name:
JENETHA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
972-763-3893

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  157 , 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)





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