Provider Demographics
NPI:1518460211
Name:DEEPBLUE WELLNESS LLC
Entity Type:Organization
Organization Name:DEEPBLUE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:VERGARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-275-4489
Mailing Address - Street 1:PO BOX 85
Mailing Address - Street 2:
Mailing Address - City:KAPLAN
Mailing Address - State:LA
Mailing Address - Zip Code:70548-0085
Mailing Address - Country:US
Mailing Address - Phone:337-643-8424
Mailing Address - Fax:337-643-8407
Practice Address - Street 1:4421 CONLIN ST STE 101
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-2145
Practice Address - Country:US
Practice Address - Phone:337-643-8424
Practice Address - Fax:337-643-8407
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NICOLAS VERGARA MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.2049642084B0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1507814Medicaid