Healthcare Provider Details

I. General information

NPI: 1164723920
Provider Name (Legal Business Name): RENAL SERVICES OF NORTHEAST LOUISIANA A PROF MED CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2010
Last Update Date: 11/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1908 ROYAL AVE
MONROE LA
71201-5724
US

IV. Provider business mailing address

1908 ROYAL AVE
MONROE LA
71201-5724
US

V. Phone/Fax

Practice location:
  • Phone: 318-325-5435
  • Fax: 318-325-8852
Mailing address:
  • Phone: 318-325-5435
  • Fax: 318-325-8852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number18516
License Number StateLA

VIII. Authorized Official

Name: DR. LARRY THOMAS OLINDE
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 318-325-5435