Provider Demographics
NPI:1538408158
Name:PREMISE HEALTH OF LOUISANNA, PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:PREMISE HEALTH OF LOUISANNA, PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEIZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-479-9063
Mailing Address - Street 1:16906 COLLECTION CENTER DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60693-0169
Mailing Address - Country:US
Mailing Address - Phone:877-865-9013
Mailing Address - Fax:337-439-7345
Practice Address - Street 1:4101 HWY 108 SOUTH EAST GATE
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:LA
Practice Address - Zip Code:70669-8017
Practice Address - Country:US
Practice Address - Phone:337-439-7324
Practice Address - Fax:337-439-7345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-01
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine