Provider Demographics
NPI:1942209713
Name:RENALSOUTH OF LOUISIANA, LLC
Entity Type:Organization
Organization Name:RENALSOUTH OF LOUISIANA, LLC
Other - Org Name:RENALSOUTH OF ST. TAMMANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-943-6700
Mailing Address - Street 1:2800 MILAN CT
Mailing Address - Street 2:SUITE 213
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35211-6912
Mailing Address - Country:US
Mailing Address - Phone:205-943-6700
Mailing Address - Fax:205-943-6697
Practice Address - Street 1:397 HIGHWAY 21
Practice Address - Street 2:SUITE 602
Practice Address - City:MADISONVILLE
Practice Address - State:LA
Practice Address - Zip Code:70447-3407
Practice Address - Country:US
Practice Address - Phone:985-792-5334
Practice Address - Fax:985-792-5234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA145261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA192674Medicare ID - Type Unspecified