Healthcare Provider Details

I. General information

NPI: 1730407966
Provider Name (Legal Business Name): LOUISIANA COMMUNITY HEALTH AND WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 05/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 PARENT ST
NEW ROADS LA
70760-2215
US

IV. Provider business mailing address

805 PARENT ST
NEW ROADS LA
70760-2215
US

V. Phone/Fax

Practice location:
  • Phone: 225-638-8878
  • Fax: 225-638-8879
Mailing address:
  • Phone: 225-638-8878
  • Fax: 225-638-8879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State

VIII. Authorized Official

Name: MR. KENDRICK EBANKS
Title or Position: CO-OWNER
Credential:
Phone: 225-638-8878