MEDICARE: LOUISDOR GAY JR. CO-OWNER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171400000X	Health & Wellness Coach

General Provider Information

NPI Number	:	1336930387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOUISDOR GAY JR. CO-OWNER

Provider Business Mailing Address
First Line	:	71 LEGION PKWY STE 26
Second Line	:
City	:	BROCKTON
State	:	MA
Zip	:	02301-7225
Country	:	US
Telephone Number	:	508-409-0489
Fax Number	:

Provider Business Practice Location Address
First Line	:	71 LEGION PKWY STE 26
Second Line	:
City	:	BROCKTON
State	:	MA
Zip	:	02301-7225
Country	:	US
Telephone Number	:	508-409-0489
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2025
Last Update Date	:	05/16/2025

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