Provider Demographics
NPI:1568413185
Name:NORTHEAST LOUISIANA KIDNEY SPECIALISTS,LLC
Entity Type:Organization
Organization Name:NORTHEAST LOUISIANA KIDNEY SPECIALISTS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/BILLING
Authorized Official - Prefix:
Authorized Official - First Name:MISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-323-8847
Mailing Address - Street 1:711 WOOD ST
Mailing Address - Street 2:STE A
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7549
Mailing Address - Country:US
Mailing Address - Phone:318-323-8847
Mailing Address - Fax:318-327-3410
Practice Address - Street 1:711 WOOD ST
Practice Address - Street 2:STE A
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-7549
Practice Address - Country:US
Practice Address - Phone:318-323-8847
Practice Address - Fax:318-327-3410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1949132Medicaid
LA1949132Medicaid