Healthcare Provider Details

I. General information

NPI: 1114687563
Provider Name (Legal Business Name): WISDOM HEALTHCARE SERVICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2021
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BOULET DR
LAFAYETTE LA
70506-2212
US

IV. Provider business mailing address

5520 JOHNSON STE K PMB 1121
LAFAYETTE LA
70503-6706
US

V. Phone/Fax

Practice location:
  • Phone: 337-279-2102
  • Fax: 337-735-1887
Mailing address:
  • Phone: 337-279-2102
  • Fax: 337-735-1887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DESTINY L LANDRY
Title or Position: CEO
Credential:
Phone: 337-230-3116