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NPI Code Detail

MEDICARE: IMMUNOLASE LLC

MEDICARE: IMMUNOLASE LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207KI0005XClinical & Laboratory Immunology (Allergy & Immunology) Physician19D2105974LA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11851325823OTHERTXNPI
21952739575OTHERAZNPI
31437117751OTHERAZNPI
41255690483OTHERAZNPI
51386653251OTHERTXNPI
61891185948OTHERAZNPI
71316972656OTHERAZNPI
81497794259OTHERMSNPI
91811939606OTHERTXNPI
101215993084OTHERTXNPI
111306275615OTHERAZNPI
121427182989OTHERTXNPI

General Provider Information

NPI Number : 1427416171
Entity Type Code : Organization
Provider Name (Legal Business Name) : IMMUNOLASE LLC
Provider Business Mailing Address
First Line : PO BOX 1414
Second Line :
City : SAGAMORE BEACH
State : MA
Zip : 02562-1414
Country : US
Telephone Number : 504-372-6250
Fax Number :
Provider Business Practice Location Address
First Line : 1901 MANHATTAN BLVD BLDG D
Second Line :
City : HARVEY
State : LA
Zip : 70058-3583
Country : US
Telephone Number : 504-372-6250
Fax Number :
Authorized Official
Title or Position : MEMBER/CEO
Name : BRENNEN LARK
Credential :
Telephone Number : 504-372-6250
Provider Enumeration Date : 02/09/2016
Last Update Date : 03/23/2018

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Directions to “IMMUNOLASE LLC ” Practice Location

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