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General NPI Number Information
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NPI Number | 1427416171
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Entity Type | Organization
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Legal Business Name | IMMUNOLASE LLC
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Dates
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Enumeration Date | 02/09/2016
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Last Update Date | 03/23/2018
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Provider Practice Location Address
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Address Line | 1901 MANHATTAN BLVD BLDG D
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City | HARVEY
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State | LA
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Zip | 70058-3583
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Country | US
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Telephone | 504-372-6250
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1414
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City | SAGAMORE BEACH
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State | MA
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Zip | 02562-1414
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Country | US
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Telephone | 504-372-6250
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Fax |
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Authorized Official
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Title or Position | MEMBER/CEO
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Name | BRENNEN LARK
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Credential |
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Telephone | 504-372-6250
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207KI0005X
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Taxonomy Name | Clinical & Laboratory Immunology (Allergy & Immunology) Physician
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License Number | 19D2105974
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License Number State | LA
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