Provider Demographics
NPI:1497301709
Name:PELICAN MEDICAL, WELLNESS, AND COSMETIC CENTER
Entity type:Organization
Organization Name:PELICAN MEDICAL, WELLNESS, AND COSMETIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAUTREAU
Authorized Official - Suffix:
Authorized Official - Credentials:CNM
Authorized Official - Phone:504-236-5311
Mailing Address - Street 1:40230 PELICAN POINT PKWY
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-8511
Mailing Address - Country:US
Mailing Address - Phone:504-236-5311
Mailing Address - Fax:
Practice Address - Street 1:6473 HWY 44
Practice Address - Street 2:UNIT 103
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-8158
Practice Address - Country:US
Practice Address - Phone:225-257-1040
Practice Address - Fax:225-257-1043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-13
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty