Provider Demographics
NPI:1699744664
Name:NORTHLAKE REHAB PROFESSIONALS
Entity type:Organization
Organization Name:NORTHLAKE REHAB PROFESSIONALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROIG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-345-0033
Mailing Address - Street 1:2101 ROBIN AVE
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-5773
Mailing Address - Country:US
Mailing Address - Phone:985-345-0033
Mailing Address - Fax:985-345-1199
Practice Address - Street 1:2101 ROBIN AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-5772
Practice Address - Country:US
Practice Address - Phone:985-345-0033
Practice Address - Fax:985-345-1199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09912R174400000X
ALAP04607363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1680818Medicaid
LA1625345Medicaid
LA1625345Medicaid
LA5C359Medicare PIN
LA1680818Medicaid