Provider Demographics
NPI:1073693958
Name:NORTHLAKE MEDICINE AND WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:NORTHLAKE MEDICINE AND WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TANIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LEVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-809-6195
Mailing Address - Street 1:1980 N HIGHWAY 190
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-5158
Mailing Address - Country:US
Mailing Address - Phone:985-809-6195
Mailing Address - Fax:985-809-6199
Practice Address - Street 1:1980 N HIGHWAY 190
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-5158
Practice Address - Country:US
Practice Address - Phone:985-809-6195
Practice Address - Fax:985-809-6199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018251261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1378054Medicaid
LAB65395Medicare UPIN
LA5CV70Medicare PIN