MEDICARE: WELLNESS EXPRESS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1205163490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLNESS EXPRESS, LLC

Provider Business Mailing Address
First Line	:	312 GUILBEAU RD STE 5D
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70506-6954
Country	:	US
Telephone Number	:	337-988-1138
Fax Number	:	337-984-5037

Provider Business Practice Location Address
First Line	:	312 GUILBEAU RD STE 5D
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70506-6954
Country	:	US
Telephone Number	:	337-988-1138
Fax Number	:	337-984-5037

Authorized Official
Title or Position	:	DIRECTOR
Name	:	SHIRLENE YOUNG MYERS
Credential	:	RN
Telephone Number	:	337-988-1138

Provider Enumeration Date	:	11/09/2009
Last Update Date	:	11/10/2009

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Directions to “WELLNESS EXPRESS, LLC ” Practice Location

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