Provider Demographics
NPI:1053742882
Name:NOLA PEDIATRICS
Entity type:Organization
Organization Name:NOLA PEDIATRICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NURSING
Authorized Official - Prefix:MS
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHOOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-468-8585
Mailing Address - Street 1:2124 DRIFTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-3574
Mailing Address - Country:US
Mailing Address - Phone:504-468-8585
Mailing Address - Fax:
Practice Address - Street 1:2124 DRIFTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-3574
Practice Address - Country:US
Practice Address - Phone:504-468-8585
Practice Address - Fax:504-468-8584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-04
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2203781882251J00000X
261QM3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0011183Medicaid