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General NPI Number Information
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NPI Number | 1518460211
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Entity Type | Organization
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Legal Business Name | DEEPBLUE WELLNESS LLC
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Dates
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Enumeration Date | 03/09/2018
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Last Update Date | 03/09/2018
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Provider Practice Location Address
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Address Line | 4421 CONLIN ST STE 101
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City | METAIRIE
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State | LA
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Zip | 70006-2145
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Country | US
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Telephone | 337-643-8424
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Fax | 337-643-8407
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Provider Business Mailing Address
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Address Line | PO BOX 85
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City | KAPLAN
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State | LA
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Zip | 70548-0085
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Country | US
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Telephone | 337-643-8424
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Fax | 337-643-8407
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Authorized Official
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Title or Position | OWNER
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Name | NICOLAS VERGARA
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Credential | MD
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Telephone | 504-275-4489
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084B0040X
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Taxonomy Name | Behavioral Neurology & Neuropsychiatry Physician
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License Number | MD.204964
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License Number State | LA
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