=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609698877
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMISE HEALTH OF LOUISIANA MEDICAL PROFESSIONAL MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2024
-----------------------------------------------------
Last Update Date | 10/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14902 RIVER RD
-----------------------------------------------------
City | NORCO
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70079-2543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-764-4666
-----------------------------------------------------
Fax | 985-764-4568
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5500 MARYLAND WAY STE 120
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-4993
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JONATHAN B LEIZMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-468-6270
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------