MEDICARE: COUVILLION WELLNESS, LLC

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	104100000X	Social Worker	5969	LA
2	225100000X	Physical Therapist	04977	LA

General Provider Information

NPI Number	:	1558679589
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUVILLION WELLNESS, LLC

Provider Business Mailing Address
First Line	:	3004 JACKSON ST
Second Line	:	SUITE A
City	:	ALEXANDRIA
State	:	LA
Zip	:	71301-4745
Country	:	US
Telephone Number	:	318-787-5952
Fax Number	:	318-787-5962

Provider Business Practice Location Address
First Line	:	3004 JACKSON ST
Second Line	:	SUITE A
City	:	ALEXANDRIA
State	:	LA
Zip	:	71301-4745
Country	:	US
Telephone Number	:	318-787-5952
Fax Number	:	318-787-5962

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	GINGER COUVILLION
Credential	:
Telephone Number	:	318-787-5952

Provider Enumeration Date	:	09/24/2010
Last Update Date	:	09/24/2010

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