Provider Demographics
NPI:1548602097
Name:INTEGRATED WELLNESS CLINIC OF LOUISIANA, LLC
Entity Type:Organization
Organization Name:INTEGRATED WELLNESS CLINIC OF LOUISIANA, LLC
Other - Org Name:INTEGRATED WELLNESS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-483-9782
Mailing Address - Street 1:10473 OLD HAMMOND HWY
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-8264
Mailing Address - Country:US
Mailing Address - Phone:252-924-1910
Mailing Address - Fax:225-924-1988
Practice Address - Street 1:10473 OLD HAMMOND HWY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-8264
Practice Address - Country:US
Practice Address - Phone:252-924-1910
Practice Address - Fax:225-924-1988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-25
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2222222Medicaid