Healthcare Provider Details

I. General information

NPI: 1194770669
Provider Name (Legal Business Name): BAYOU LA BATRE AREA HEALTH DEVELOPMENT BD.INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 NORTH WINTZELL AVE.
BAYOU LA BATRE AL
36509
US

IV. Provider business mailing address

PO BOX 769
BAYOU LA BATRE AL
36509-0769
US

V. Phone/Fax

Practice location:
  • Phone: 251-824-2347
  • Fax: 251-824-4337
Mailing address:
  • Phone: 251-824-2347
  • Fax: 251-824-4337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2006-293
License Number StateAL

VIII. Authorized Official

Name: MR. JAMES A. HOLLAND
Title or Position: CEO
Credential: MPH
Phone: 251-824-2174