=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669821930
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLISTICS PHYSICAL THERAPY CENTER L3C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2016
-----------------------------------------------------
Last Update Date | 02/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4228 WILLIAMS BLVD STE 201
-----------------------------------------------------
City | KENNER
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70065-2270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-224-8400
-----------------------------------------------------
Fax | 504-272-0237
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4228 WILLIAMS BLVD STE 201
-----------------------------------------------------
City | KENNER
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70065-2270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-224-8400
-----------------------------------------------------
Fax | 504-272-0237
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. GRISELDA ADAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 504-224-8400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------