Healthcare Provider Details

I. General information

NPI: 1518460211
Provider Name (Legal Business Name): DEEPBLUE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

4421 CONLIN ST STE 101
METAIRIE LA
70006-2145
US

IV. Provider business mailing address

PO BOX 85
KAPLAN LA
70548-0085
US

V. Phone/Fax

Practice location:
  • Phone: 337-643-8424
  • Fax: 337-643-8407
Mailing address:
  • Phone: 337-643-8424
  • Fax: 337-643-8407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License NumberMD.204964
License Number StateLA

VIII. Authorized Official

Name: NICOLAS VERGARA
Title or Position: OWNER
Credential: MD
Phone: 504-275-4489