Provider Demographics
NPI:1962531483
Name:NORTHLAKE SURGICAL ASSOCIATES, LTD A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:NORTHLAKE SURGICAL ASSOCIATES, LTD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SABRINA
Authorized Official - Middle Name:W
Authorized Official - Last Name:HEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-892-3766
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70434-0128
Mailing Address - Country:US
Mailing Address - Phone:985-892-3766
Mailing Address - Fax:985-893-9567
Practice Address - Street 1:606 W 11TH AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-3630
Practice Address - Country:US
Practice Address - Phone:985-892-3766
Practice Address - Fax:985-893-9567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1791873Medicaid
LA1791873Medicaid