Provider Demographics
NPI:1164989802
Name:LAKE WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:LAKE WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSSEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-703-0880
Mailing Address - Street 1:501 W SAINT MARY BLVD STE 308
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-4600
Mailing Address - Country:US
Mailing Address - Phone:337-781-3408
Mailing Address - Fax:
Practice Address - Street 1:3620 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-3615
Practice Address - Country:US
Practice Address - Phone:505-676-5253
Practice Address - Fax:504-676-5151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility