MEDICARE: BAYOU LA BATRE AREA HEALTH DEVELOPMENT BOARD, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	PHL L6503	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	01DO692409	OTHER	AL	CLIA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023068459
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYOU LA BATRE AREA HEALTH DEVELOPMENT BOARD, INC.

Provider Business Mailing Address
First Line	:	P.O. BOX 415
Second Line	:	7777 HWY 43 NORTH
City	:	MC INTOSH
State	:	AL
Zip	:	36553-0415
Country	:	US
Telephone Number	:	251-944-2842
Fax Number	:	251-944-8070

Provider Business Practice Location Address
First Line	:	7777 HIGHWAY 43 NORTH
Second Line	:
City	:	MCINTOSH
State	:	AL
Zip	:	36553-0415
Country	:	US
Telephone Number	:	251-944-2842
Fax Number	:	251-944-8070

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. JAMES A. HOLLAND
Credential	:	MPH
Telephone Number	:	251-824-2174

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	04/25/2013

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