1740647866 NPI number — MEDLEADERS LLC

Table of content: (NPI 1740647866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740647866 NPI number — MEDLEADERS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDLEADERS 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:
6
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:
1740647866
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 78070
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:
70837-8070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-243-6997
Provider Business Mailing Address Fax Number:
225-243-7157

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8369 FLORIDA BLVD
Provider Second Line Business Practice Location Address:
SUITE 9
Provider Business Practice Location Address City Name:
DENHAM SPRINGS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70726-7862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-243-6997
Provider Business Practice Location Address Fax Number:
225-243-7157
Provider Enumeration Date:
01/20/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ALTAZIN
Authorized Official First Name:
COURTNEY
Authorized Official Middle Name:
LEIGH
Authorized Official Title or Position:
OPERATIONS MANAGER
Authorized Official Telephone Number:
225-243-6997

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  025596 , 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: 025596 . This is a "LICENSE NUMBER" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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