Provider Demographics
NPI:1497250609
Name:ULTIMATE HEALING WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:ULTIMATE HEALING WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GENENE
Authorized Official - Middle Name:MCDONALD
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:504-442-6943
Mailing Address - Street 1:2856 GLENBROOK DR
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-7910
Mailing Address - Country:US
Mailing Address - Phone:504-442-6943
Mailing Address - Fax:
Practice Address - Street 1:2856 GLENBROOK DR
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-7910
Practice Address - Country:US
Practice Address - Phone:504-442-6943
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA132708Medicaid