Provider Demographics
NPI:1548561301
Name:KIDNEY SERVICES OF NORTHEAST LA A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:KIDNEY SERVICES OF NORTHEAST LA A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:YOUNT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-325-5435
Mailing Address - Street 1:1908 ROYAL AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5724
Mailing Address - Country:US
Mailing Address - Phone:318-325-5435
Mailing Address - Fax:318-325-8852
Practice Address - Street 1:1908 ROYAL AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5724
Practice Address - Country:US
Practice Address - Phone:318-325-5435
Practice Address - Fax:318-325-8852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA21145207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty