Healthcare Provider Details

I. General information

NPI: 1588677454
Provider Name (Legal Business Name): BAYOU ORTHOTIC AND PROSTHETIC CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 03/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3717 VONNIE DR
HARVEY LA
70058-2354
US

IV. Provider business mailing address

3717 VONNIE DR
HARVEY LA
70058-2354
US

V. Phone/Fax

Practice location:
  • Phone: 504-341-1331
  • Fax: 504-341-1341
Mailing address:
  • Phone: 504-341-1331
  • Fax: 504-341-1341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. KENNETH R. BORDELON
Title or Position: PARTNER/CEO
Credential: C.P.O.
Phone: 504-341-1331