Healthcare Provider Details

I. General information

NPI: 1528525268
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: 03/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4540 AMBASSADOR CAFFERY PKWY STE C110
LAFAYETTE LA
70508-6937
US

IV. Provider business mailing address

501 W SAINT MARY BLVD STE 308
LAFAYETTE LA
70506-4600
US

V. Phone/Fax

Practice location:
  • Phone: 337-346-5253
  • Fax: 337-703-0707
Mailing address:
  • Phone: 337-703-0880
  • 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