| Organization Name: | SOUTH LOUISIANA WELLNESS SERVICES LLC |
| NPI Number: | 1700257615 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | PAMELA DUPONT (AGENT) |
| Mailing Address: | 4266 W Main St Ste 100 Gray |
| State: | LA US |
| Postal Code: | 703596421 |
| Phone Number: | 9858567893 |
| Fax Number: | 9853466944 |
| NPI Enumeration Date: | 10/19/2015 |
| NPI Last Update Date: | 10/19/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |