Healthcare Provider Details

I. General information

NPI: 1184147498
Provider Name (Legal Business Name): ENID HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 N I 10 SERVICE RD W
METAIRIE LA
70006-6525
US

IV. Provider business mailing address

14 PONY LN
SAINT ROSE LA
70087-3638
US

V. Phone/Fax

Practice location:
  • Phone: 202-615-4832
  • Fax:
Mailing address:
  • Phone: 202-615-4832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number StateLA

VIII. Authorized Official

Name: MS. ENID KNOCKUM
Title or Position: OWNER
Credential:
Phone: 202-615-4832