Basic Information
| Provider Information | |||||||||
| NPI: | 1235523085 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULF SOUTH ADDICTION & WELNESS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1539 JACKSON AVE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701305858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857810548 | ||||||||
| FaxNumber: | 9857814319 | ||||||||
| Practice Location | |||||||||
| Address1: | 1539 JACKSON AVE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701305858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857810548 | ||||||||
| FaxNumber: | 9857814319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2015 | ||||||||
| LastUpdateDate: | 03/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | MALLIK | ||||||||
| AuthorizedOfficialFirstName: | HARMINDER | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9857810548 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 2203782288 | LA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 2203782288 | 01 | LA | STATE LICENSE | OTHER |