Healthcare Provider Details

I. General information

NPI: 1043814486
Provider Name (Legal Business Name): HEADACHE AND WELLNESS CENTER OF SOUTHWEST LOUISIANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 09/01/2021
Certification Date: 09/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 W BAYOU PINES DR STE B
LAKE CHARLES LA
70601-7096
US

IV. Provider business mailing address

803 W BAYOU PINES DR STE B
LAKE CHARLES LA
70601-7096
US

V. Phone/Fax

Practice location:
  • Phone: 337-508-2333
  • Fax:
Mailing address:
  • Phone: 337-508-2333
  • Fax: 337-549-6316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. DARCI L PORTIE
Title or Position: OWNER
Credential: NP
Phone: 337-508-2333