Provider Demographics
NPI:1821742040
Name:NIGHTWATER HEALTH OF LOUISIANA, INC
Entity Type:Organization
Organization Name:NIGHTWATER HEALTH OF LOUISIANA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:IKEMIRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-717-3050
Mailing Address - Street 1:111 WATER ST STE 4
Mailing Address - Street 2:
Mailing Address - City:EXETER
Mailing Address - State:NH
Mailing Address - Zip Code:03833-2456
Mailing Address - Country:US
Mailing Address - Phone:504-717-3050
Mailing Address - Fax:504-617-6371
Practice Address - Street 1:719 OKEEFE AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70113-1906
Practice Address - Country:US
Practice Address - Phone:504-381-4204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NIGHTWATER HEALTH, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-02-07
Last Update Date:2022-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAMD.205087OtherLSMBE