Healthcare Provider Details

I. General information

NPI: 1568413185
Provider Name (Legal Business Name): NORTHEAST LOUISIANA KIDNEY SPECIALISTS,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 12/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 WOOD ST STE A
MONROE LA
71201-7549
US

IV. Provider business mailing address

711 WOOD ST STE A
MONROE LA
71201-7549
US

V. Phone/Fax

Practice location:
  • Phone: 318-323-8847
  • Fax: 318-327-3410
Mailing address:
  • Phone: 318-323-8847
  • Fax: 318-327-3410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MISTI WILLIAMS
Title or Position: CREDENTIALING/BILLING
Credential:
Phone: 318-323-8847