Provider Demographics
NPI:1043814486
Name:HEADACHE AND WELLNESS CENTER OF SOUTHWEST LOUISIANA, LLC
Entity type:Organization
Organization Name:HEADACHE AND WELLNESS CENTER OF SOUTHWEST LOUISIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DARCI
Authorized Official - Middle Name:L
Authorized Official - Last Name:PORTIE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:337-508-2333
Mailing Address - Street 1:803 W BAYOU PINES DR STE B
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7096
Mailing Address - Country:US
Mailing Address - Phone:337-508-2333
Mailing Address - Fax:337-549-6316
Practice Address - Street 1:803 W BAYOU PINES DR STE B
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7096
Practice Address - Country:US
Practice Address - Phone:337-508-2333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-25
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty