Provider Demographics
NPI:1093711426
Name:PET CENTER OF LOUISIANA LLC
Entity Type:Organization
Organization Name:PET CENTER OF LOUISIANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:504-887-8728
Mailing Address - Street 1:PO BOX 6315
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70009-6315
Mailing Address - Country:US
Mailing Address - Phone:985-345-8867
Mailing Address - Fax:985-542-5322
Practice Address - Street 1:1495 GAUSE BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2205
Practice Address - Country:US
Practice Address - Phone:504-887-8728
Practice Address - Fax:504-887-8702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA445353261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1441520Medicaid
LA1441520Medicaid