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General NPI Number Information
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NPI Number | 1073693958
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Entity Type | Organization
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Legal Business Name | NORTHLAKE MEDICINE AND WELLNESS CENTER, LLC
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Dates
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Enumeration Date | 10/16/2006
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Last Update Date | 08/16/2010
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Provider Practice Location Address
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Address Line | 1980 N HIGHWAY 190
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City | COVINGTON
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State | LA
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Zip | 70433-5158
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Country | US
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Telephone | 985-809-6195
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Fax | 985-809-6199
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Provider Business Mailing Address
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Address Line | 1980 N HIGHWAY 190
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City | COVINGTON
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State | LA
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Zip | 70433-5158
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Country | US
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Telephone | 985-809-6195
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Fax | 985-809-6199
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Authorized Official
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Title or Position | OWNER
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Name | DR. TANIA ANN LEVI
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Credential | M.D.
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Telephone | 985-809-6195
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 018251
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License Number State | LA
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