Basic Information
| Provider Information | |||||||||
| NPI: | 1700333689 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PMR LA HOLDING, LLC | ||||||||
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| OtherOrganizationName: | JENCARE SENIOR MEDICAL CENTER - METAIRIE II | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1395 NW 167TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331695742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058314760 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3530 HOUMA BLVD | ||||||||
| Address2: | |||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5042645142 | ||||||||
| FaxNumber: | 5043081285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2016 | ||||||||
| LastUpdateDate: | 10/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | CHEN | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3056286117 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | N | Suppliers | Non-Pharmacy Dispensing Site | 333600000X | PHY.007546-IR | LA | N | Suppliers | Pharmacy | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.