Provider Demographics
NPI:1306010566
Name:NORTHLAKE INTERVENTIONAL PAIN MANAGEMENT, LLC
Entity Type:Organization
Organization Name:NORTHLAKE INTERVENTIONAL PAIN MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:N
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-690-8335
Mailing Address - Street 1:PO BOX 54056
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70154-4056
Mailing Address - Country:US
Mailing Address - Phone:985-690-8335
Mailing Address - Fax:985-690-8334
Practice Address - Street 1:985 ROBERT BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2063
Practice Address - Country:US
Practice Address - Phone:985-690-8335
Practice Address - Fax:985-690-8334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty