Basic Information
| Provider Information | |||||||||
| NPI: | 1073962528 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEURO CARE OF LOUISIANA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 648 CRESTWOOD DRIVE | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858052555 | ||||||||
| FaxNumber: | 9854005303 | ||||||||
| Practice Location | |||||||||
| Address1: | 648 CRESTWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704336521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858052555 | ||||||||
| FaxNumber: | 9854005303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2016 | ||||||||
| LastUpdateDate: | 07/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | EL KHOURY | ||||||||
| AuthorizedOfficialFirstName: | RAMY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9858052555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 2324373 | 05 | LA | MEDICAID |