1558502971 NPI number — EARL J PRIMO MS OD LLC

Table of content: (NPI 1558502971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558502971 NPI number — EARL J PRIMO MS OD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EARL J PRIMO MS OD 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:
1558502971
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 STONEWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINGTON
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70433-5819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-606-1701
Provider Business Mailing Address Fax Number:
985-871-9953

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
880 N HIGHWAY 190
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70433-5147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-867-8708
Provider Business Practice Location Address Fax Number:
985-867-8711
Provider Enumeration Date:
03/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PRIMO
Authorized Official First Name:
EARL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
985-867-8708

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1332-466T , 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)

  • Identifier: 1153796 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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