Provider Demographics
NPI:1407120785
Name:IMMUNIZATION SERVICES OF LOUISIANA, LLC
Entity Type:Organization
Organization Name:IMMUNIZATION SERVICES OF LOUISIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:HEDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:504-430-3397
Mailing Address - Street 1:1608 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-2712
Mailing Address - Country:US
Mailing Address - Phone:504-430-3397
Mailing Address - Fax:504-828-7640
Practice Address - Street 1:1608 DIVISION ST
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-2712
Practice Address - Country:US
Practice Address - Phone:504-430-3397
Practice Address - Fax:504-828-7640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-03
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA17258261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health