Provider Demographics
NPI:1457648321
Name:CLINICAL CONSULTANTS OF LOUISIANA LLC
Entity Type:Organization
Organization Name:CLINICAL CONSULTANTS OF LOUISIANA LLC
Other - Org Name:DIMITRI DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:CALLENDER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:504-512-2206
Mailing Address - Street 1:3723 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-3025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9930 LAKE FOREST BLVD
Practice Address - Street 2:STE. B
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70127-5483
Practice Address - Country:US
Practice Address - Phone:504-512-2206
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center