Healthcare Provider Details

I. General information

NPI: 1114010667
Provider Name (Legal Business Name): BAKER WELLNESS CENTER ADHC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 MAIN STREET
BAKER LA
70714
US

IV. Provider business mailing address

P.O. BOX 668
BAKER LA
70704
US

V. Phone/Fax

Practice location:
  • Phone: 225-778-1567
  • Fax: 225-771-1520
Mailing address:
  • Phone: 225-778-1567
  • Fax: 225-771-1520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number2020
License Number StateLA

VIII. Authorized Official

Name: DR. RODOLFO M MANALAC
Title or Position: OWNER/PRESIDENT
Credential: M.D.
Phone: 225-778-1567