Healthcare Provider Details

I. General information

NPI: 1083854087
Provider Name (Legal Business Name): BAYOU WELLNESS CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27403 HWY 190, SUITE B
LACOMBE LA
70445-1550
US

IV. Provider business mailing address

PO BOX 1550 27403 HWY 190, SUITE B
LACOMBE LA
70445-1550
US

V. Phone/Fax

Practice location:
  • Phone: 985-218-9555
  • Fax: 985-218-9557
Mailing address:
  • Phone: 985-218-9555
  • Fax: 985-218-9557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: MISS LINDA MARIE ANDERSON
Title or Position: CEO/OWNER
Credential:
Phone: 985-218-9556