Provider Demographics
NPI:1760643670
Name:NEUROMEDICAL CLINIC OF CENLA,L.L.C.
Entity Type:Organization
Organization Name:NEUROMEDICAL CLINIC OF CENLA,L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GONZALO
Authorized Official - Middle Name:IVAR
Authorized Official - Last Name:HIDALGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-443-0490
Mailing Address - Street 1:3311 PRESCOTT RD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3900
Mailing Address - Country:US
Mailing Address - Phone:318-443-0490
Mailing Address - Fax:318-443-0690
Practice Address - Street 1:3311 PRESCOTT RD
Practice Address - Street 2:SUITE 216
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3900
Practice Address - Country:US
Practice Address - Phone:318-443-0490
Practice Address - Fax:318-443-0690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025214305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1108162Medicaid
LA4A824Medicare PIN
LAH51389Medicare UPIN