Healthcare Provider Details

I. General information

NPI: 1770213217
Provider Name (Legal Business Name): BIOACTIVE INFUSION & WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W LOUISIANA AVE
RAYNE LA
70578-5912
US

IV. Provider business mailing address

100 W LOUISIANA AVE
RAYNE LA
70578-5912
US

V. Phone/Fax

Practice location:
  • Phone: 337-581-7009
  • Fax:
Mailing address:
  • Phone: 337-581-7009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY GATTE
Title or Position: CO-OWNER
Credential: FNPC
Phone: 337-581-7009