Healthcare Provider Details

I. General information

NPI: 1114996865
Provider Name (Legal Business Name): BAYOUCLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 10/14/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13833 TAPIA AVE
BAYOU LA BATRE AL
36509-2515
US

IV. Provider business mailing address

13220 N WINTZELL AVE
BAYOU LA BATRE AL
36509-2142
US

V. Phone/Fax

Practice location:
  • Phone: 251-824-4985
  • Fax: 251-824-4990
Mailing address:
  • Phone: 251-824-4985
  • Fax: 251-824-4990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateAL

VIII. Authorized Official

Name: JULIE H TAYLOR
Title or Position: INTERIM EXECUTIVE DIRECTOR
Credential:
Phone: 251-824-4985