Healthcare Provider Details

I. General information

NPI: 1083898571
Provider Name (Legal Business Name): BAYOU HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 JOHN ESKEW DR
ALEXANDRIA LA
71303-0000
US

IV. Provider business mailing address

44 VERSAILLES BLVD
ALEXANDRIA LA
71303
US

V. Phone/Fax

Practice location:
  • Phone: 318-445-5111
  • Fax: 318-767-1307
Mailing address:
  • Phone: 318-445-5111
  • Fax: 318-442-2261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number433
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number695
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number695
License Number StateLA

VIII. Authorized Official

Name: MS. GWENDOLYN LEWIS
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 318-448-7317