Basic Information
Provider Information
NPI: 1497301709
EntityType: 2
ReplacementNPI:  
OrganizationName: PELICAN MEDICAL, WELLNESS, AND COSMETIC CENTER
LastName:  
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Credential:  
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Mailing Information
Address1: 40230 PELICAN POINT PKWY
Address2:  
City: GONZALES
State: LA
PostalCode: 707378511
CountryCode: US
TelephoneNumber: 5042365311
FaxNumber:  
Practice Location
Address1: 6473 HWY 44
Address2: UNIT 103
City: GONZALES
State: LA
PostalCode: 707378158
CountryCode: US
TelephoneNumber: 2252571040
FaxNumber: 2252571043
Other Information
ProviderEnumerationDate: 08/13/2019
LastUpdateDate: 08/19/2021
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: GAUTREAU
AuthorizedOfficialFirstName: PEGGY
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AuthorizedOfficialTitleorPosition: MANAGING MEMBER
AuthorizedOfficialTelephone: 5042365311
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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AuthorizedOfficialCredential: CNM
NPICertificationDate: 08/19/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QP2300X  Y Ambulatory Health Care FacilitiesClinic/CenterPrimary Care

No ID Information.


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