Healthcare Provider Details

I. General information

NPI: 1134304330
Provider Name (Legal Business Name): BAYOU HOME BUREAU
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 01/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8057 WILLIARD RD
BASTROP LA
71220-8939
US

IV. Provider business mailing address

8057 WILLIARD RD PO BOX 561
BASTROP LA
71220-8939
US

V. Phone/Fax

Practice location:
  • Phone: 318-556-0043
  • Fax: 318-556-3633
Mailing address:
  • Phone: 318-556-0043
  • Fax: 318-556-3633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License NumberPCA8246
License Number StateLA

VIII. Authorized Official

Name: MRS. JUANETTA MARTIN
Title or Position: OWNER
Credential: LPN
Phone: 318-556-0043