Healthcare Provider Details

I. General information

NPI: 1942202221
Provider Name (Legal Business Name): NORTHLAKE ENDOSCOPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16061 DOCTORS BLVD SUITE A
HAMMOND LA
70403-1479
US

IV. Provider business mailing address

16061 DOCTORS BLVD SUITE A
HAMMOND LA
70403-1479
US

V. Phone/Fax

Practice location:
  • Phone: 985-542-1334
  • Fax: 985-318-1004
Mailing address:
  • Phone: 985-542-1334
  • Fax: 985-318-1004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateLA

VIII. Authorized Official

Name: MRS. CHARLENE PIERSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 985-542-1334