Healthcare Provider Details

I. General information

NPI: 1700354453
Provider Name (Legal Business Name): OH PROJECT- NORTHSHORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2018
Last Update Date: 11/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 GREENBRIER BLVD STE 105
COVINGTON LA
70433-7237
US

IV. Provider business mailing address

PO BOX 957
MADISONVILLE LA
70447-0957
US

V. Phone/Fax

Practice location:
  • Phone: 985-276-3040
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TYRONE LUSTER
Title or Position: OWNER
Credential:
Phone: 901-626-2129