1942209713 NPI number — RENALSOUTH OF LOUISIANA, LLC

Table of content: (NPI 1942209713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942209713 NPI number — RENALSOUTH OF LOUISIANA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENALSOUTH OF LOUISIANA, 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:
RENALSOUTH OF ST. TAMMANY
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:
1942209713
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2800 MILAN CT
Provider Second Line Business Mailing Address:
SUITE 213
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35211-6912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-943-6700
Provider Business Mailing Address Fax Number:
205-943-6697

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
397 HIGHWAY 21
Provider Second Line Business Practice Location Address:
SUITE 602
Provider Business Practice Location Address City Name:
MADISONVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70447-3407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-792-5334
Provider Business Practice Location Address Fax Number:
985-792-5234
Provider Enumeration Date:
07/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CARTER
Authorized Official First Name:
TOMMY
Authorized Official Middle Name:
JAY
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
205-943-6700

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  145 , 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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