Healthcare Provider Details

I. General information

NPI: 1821742040
Provider Name (Legal Business Name): NIGHTWATER HEALTH OF LOUISIANA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 12/03/2022
Certification Date: 12/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 OKEEFE AVE
NEW ORLEANS LA
70113-1906
US

IV. Provider business mailing address

111 WATER ST STE 4
EXETER NH
03833-2456
US

V. Phone/Fax

Practice location:
  • Phone: 504-381-4204
  • Fax:
Mailing address:
  • Phone: 504-717-3050
  • Fax: 504-617-6371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PAUL IKEMIRE
Title or Position: CMO
Credential: MD
Phone: 504-717-3050