=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699744664
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHLAKE REHAB PROFESSIONALS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2006
-----------------------------------------------------
Last Update Date | 04/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2101 ROBIN AVE
-----------------------------------------------------
City | HAMMOND
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70403-5772
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-345-0033
-----------------------------------------------------
Fax | 985-345-1199
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2101 ROBIN AVE
-----------------------------------------------------
City | HAMMOND
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70403-5773
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-345-0033
-----------------------------------------------------
Fax | 985-345-1199
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RANDOLPH L ROIG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 985-345-0033
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | AP04607
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 09912R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------