Provider Demographics
NPI:1902019052
Name:NORTHLAKE EYE CENTER, APMC
Entity Type:Organization
Organization Name:NORTHLAKE EYE CENTER, APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRELL
Authorized Official - Middle Name:M
Authorized Official - Last Name:HEMELT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-643-6355
Mailing Address - Street 1:2243 GAUSE BLVD E
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-4232
Mailing Address - Country:US
Mailing Address - Phone:985-643-6355
Mailing Address - Fax:985-643-0130
Practice Address - Street 1:2243 GAUSE BLVD E
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-4232
Practice Address - Country:US
Practice Address - Phone:985-643-6355
Practice Address - Fax:985-643-0130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL023111174400000X
LAL014236174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA=========0OtherBLUE CROSS
LA=========0OtherBLUE CROSS
LAB62722Medicare UPIN