Provider Demographics
NPI:1114964483
Name:NORTHLAKE MEDICAL SUPPLY, INC
Entity Type:Organization
Organization Name:NORTHLAKE MEDICAL SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:TEBBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-377-1358
Mailing Address - Street 1:PO BOX 2737
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70434-2737
Mailing Address - Country:US
Mailing Address - Phone:985-892-7709
Mailing Address - Fax:985-892-7322
Practice Address - Street 1:70360 HIGHWAY 21 STE 2
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-8145
Practice Address - Country:US
Practice Address - Phone:985-892-7709
Practice Address - Fax:985-892-7322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1343692Medicaid
LA1343692Medicaid
LA0305470001Medicare NSC