Provider Demographics
NPI:1427416171
Name:IMMUNOLASE LLC
Entity Type:Organization
Organization Name:IMMUNOLASE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRENNEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-372-6250
Mailing Address - Street 1:PO BOX 1414
Mailing Address - Street 2:
Mailing Address - City:SAGAMORE BEACH
Mailing Address - State:MA
Mailing Address - Zip Code:02562-1414
Mailing Address - Country:US
Mailing Address - Phone:504-372-6250
Mailing Address - Fax:
Practice Address - Street 1:1901 MANHATTAN BLVD BLDG D
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:LA
Practice Address - Zip Code:70058-3583
Practice Address - Country:US
Practice Address - Phone:504-372-6250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-09
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA19D2105974207KI0005X
207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Yes207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory ImmunologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1851325823OtherNPI
AZ1952739575OtherNPI
AZ1437117751OtherNPI
AZ1255690483OtherNPI
TX1386653251OtherNPI
AZ1891185948OtherNPI
AZ1316972656OtherNPI
MS1497794259OtherNPI
TX1811939606OtherNPI
TX1215993084OtherNPI
AZ1306275615OtherNPI
TX1427182989OtherNPI
AZ1952739575OtherNPI
TX1427182989OtherNPI