Healthcare Provider Details

I. General information

NPI: 1285180158
Provider Name (Legal Business Name): NORTHSHORE PROVIDER GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 08/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48529 RED FOX DR
HAMMOND LA
70401-3715
US

IV. Provider business mailing address

PO BOX 1063
HAMMOND LA
70404-1063
US

V. Phone/Fax

Practice location:
  • Phone: 337-315-9686
  • Fax:
Mailing address:
  • Phone: 337-315-9686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES I MATHEWS
Title or Position: OWNER
Credential:
Phone: 337-315-9686