Healthcare Provider Details

I. General information

NPI: 1205125374
Provider Name (Legal Business Name): INFINITE HEALTH INTEGRATIVE MEDICINE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 W WALNUT ST STE 2
LAKE CHARLES LA
70601-5690
US

IV. Provider business mailing address

2002 W WALNUT ST STE 2
LAKE CHARLES LA
70601-5690
US

V. Phone/Fax

Practice location:
  • Phone: 337-312-8234
  • Fax: 337-312-8411
Mailing address:
  • Phone: 337-312-8234
  • Fax: 337-312-8411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QX0200X
TaxonomyOncology Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. HENRY JACKSON GOOLSBY III
Title or Position: PRESIDENT
Credential: M.D.
Phone: 337-312-8234