Healthcare Provider Details

I. General information

NPI: 1740045509
Provider Name (Legal Business Name): CHALMETTE WELLNESS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2024
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013B W JUDGE PEREZ DR
CHALMETTE LA
70043-4703
US

IV. Provider business mailing address

1013B W JUDGE PEREZ DR
CHALMETTE LA
70043-4703
US

V. Phone/Fax

Practice location:
  • Phone: 504-272-0115
  • Fax: 504-366-5260
Mailing address:
  • Phone: 504-272-0115
  • Fax: 504-366-5260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN GOVAN WORK
Title or Position: MEDICAL DIRECTOR/PHYSICIAN
Credential: MD
Phone: 504-272-0115