Provider Demographics
NPI:1609698877
Name:PREMISE HEALTH OF LOUISIANA MEDICAL PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:PREMISE HEALTH OF LOUISIANA MEDICAL PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:LEIZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-468-6270
Mailing Address - Street 1:5500 MARYLAND WAY STE 120
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4993
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14902 RIVER RD
Practice Address - Street 2:
Practice Address - City:NORCO
Practice Address - State:LA
Practice Address - Zip Code:70079-2543
Practice Address - Country:US
Practice Address - Phone:985-764-4666
Practice Address - Fax:985-764-4568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty