Healthcare Provider Details

I. General information

NPI: 1073260519
Provider Name (Legal Business Name): MICHAEL SHANE BOWLING BOCO, BOCP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2022
Last Update Date: 03/03/2023
Certification Date: 03/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5412 DIJON DR
BATON ROUGE LA
70808-4315
US

IV. Provider business mailing address

631 COUNTY ROAD 837
BOAZ AL
35957-8154
US

V. Phone/Fax

Practice location:
  • Phone: 225-615-8693
  • Fax: 888-544-6008
Mailing address:
  • Phone: 256-619-1389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberC46945
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: