1669428140 NPI number — MMO OF COVINGTON, LLC

Table of content: (NPI 1669428140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669428140 NPI number — MMO OF COVINGTON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MMO OF COVINGTON, 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:
NORTH LAKE COMMUNITY MENTAL HEALTH, LLC
Provider Other Organization Name Type Code:
4
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:
1669428140
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
728 NORTH BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70802-5724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-293-6774
Provider Business Mailing Address Fax Number:
225-291-9229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 GREENBRIAR BLVD
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:
70433-7236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-249-7780
Provider Business Practice Location Address Fax Number:
985-249-7782
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
EXECUTIVE OFFICER
Authorized Official Telephone Number:
225-293-6774

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  194701 , 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: 8303 . This is a "OCCUPATIONAL LICENSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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