Healthcare Provider Details

I. General information

NPI: 1427416171
Provider Name (Legal Business Name): IMMUNOLASE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 03/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 MANHATTAN BLVD BLDG D
HARVEY LA
70058-3583
US

IV. Provider business mailing address

PO BOX 1414
SAGAMORE BEACH MA
02562-1414
US

V. Phone/Fax

Practice location:
  • Phone: 504-372-6250
  • Fax:
Mailing address:
  • Phone: 504-372-6250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License Number19D2105974
License Number StateLA

VIII. Authorized Official

Name: BRENNEN LARK
Title or Position: MEMBER/CEO
Credential:
Phone: 504-372-6250