Healthcare Provider Details

I. General information

NPI: 1770932287
Provider Name (Legal Business Name): NORTHLAKE NEPHROLOGY PHYSICIANS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2016
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 N HIGHWAY 190
COVINGTON LA
70433-5158
US

IV. Provider business mailing address

1970 N HIGHWAY 190
COVINGTON LA
70433-5158
US

V. Phone/Fax

Practice location:
  • Phone: 985-867-8585
  • Fax: 985-867-3644
Mailing address:
  • Phone: 985-867-8585
  • Fax: 985-867-3644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD.207725
License Number StateLA

VIII. Authorized Official

Name: MELISSA INMAN
Title or Position: MD
Credential: MD
Phone: 985-867-8585