Healthcare Provider Details

I. General information

NPI: 1699744664
Provider Name (Legal Business Name): NORTHLAKE REHAB PROFESSIONALS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ROBIN AVE
HAMMOND LA
70403-5772
US

IV. Provider business mailing address

2101 ROBIN AVE
HAMMOND LA
70403-5773
US

V. Phone/Fax

Practice location:
  • Phone: 985-345-0033
  • Fax: 985-345-1199
Mailing address:
  • Phone: 985-345-0033
  • Fax: 985-345-1199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number09912R
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP04607
License Number StateAL

VIII. Authorized Official

Name: DR. RANDOLPH L ROIG
Title or Position: OWNER
Credential: M.D.
Phone: 985-345-0033