Provider Demographics
NPI:1457604969
Name:PAM II OF COVINGTON, LLC
Entity Type:Organization
Organization Name:PAM II OF COVINGTON, LLC
Other - Org Name:NORTHSHORE SPECIALTY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:ASBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-213-9571
Mailing Address - Street 1:20050 CRESTWOOD BLVD
Mailing Address - Street 2:WOUND CARE CENTER
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-5207
Mailing Address - Country:US
Mailing Address - Phone:985-875-7525
Mailing Address - Fax:985-875-1934
Practice Address - Street 1:20050 CRESTWOOD BLVD
Practice Address - Street 2:WOUND CARE CENTER
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-5207
Practice Address - Country:US
Practice Address - Phone:985-875-7525
Practice Address - Fax:985-875-1934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA680282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1703176Medicaid
LA1703176Medicaid