MEDICARE: ASCENSION WELLNESS CENTER 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1477661676
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASCENSION WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	2255 S BURNSIDE AVE
Second Line	:
City	:	GONZALES
State	:	LA
Zip	:	70737-4642
Country	:	US
Telephone Number	:	225-644-3315
Fax Number	:

Provider Business Practice Location Address
First Line	:	2255 S BURNSIDE AVE
Second Line	:
City	:	GONZALES
State	:	LA
Zip	:	70737-4642
Country	:	US
Telephone Number	:	225-644-3315
Fax Number	:	225-644-4315

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. WENDELL BRUCE SMITH
Credential	:	RN
Telephone Number	:	225-644-3315

Provider Enumeration Date	:	08/28/2006
Last Update Date	:	08/22/2020

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