Healthcare Provider Details

I. General information

NPI: 1790242436
Provider Name (Legal Business Name): LAKE WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2019
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19411 HELENBIRG RD STE 101
COVINGTON LA
70433-5199
US

IV. Provider business mailing address

PO BOX 53038
LAFAYETTE LA
70505-3038
US

V. Phone/Fax

Practice location:
  • Phone: 985-602-5253
  • Fax: 985-317-2323
Mailing address:
  • Phone: 337-781-3408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: GEORGE ROUSSEL
Title or Position: OWNER
Credential:
Phone: 337-703-0880