Provider Demographics
NPI:1700354453
Name:OH PROJECT- NORTHSHORE
Entity Type:Organization
Organization Name:OH PROJECT- NORTHSHORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYRONE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-626-2129
Mailing Address - Street 1:PO BOX 957
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-0957
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:190 GREENBRIER BLVD STE 105
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7237
Practice Address - Country:US
Practice Address - Phone:985-276-3040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OHANA HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty