Provider Demographics
NPI:1114010667
Name:BAKER WELLNESS CENTER ADHC
Entity Type:Organization
Organization Name:BAKER WELLNESS CENTER ADHC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:M
Authorized Official - Last Name:MANALAC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-778-1567
Mailing Address - Street 1:P.O. BOX 668
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:LA
Mailing Address - Zip Code:70704
Mailing Address - Country:US
Mailing Address - Phone:225-778-1567
Mailing Address - Fax:225-771-1520
Practice Address - Street 1:2402 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:LA
Practice Address - Zip Code:70714
Practice Address - Country:US
Practice Address - Phone:225-778-1567
Practice Address - Fax:225-771-1520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2020311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1643360Medicaid