Healthcare Provider Details

I. General information

NPI: 1972464162
Provider Name (Legal Business Name): BAYOU KIDNEY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2025
Last Update Date: 11/19/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDALIST AVE
LAFAYETTE LA
70506-7503
US

IV. Provider business mailing address

200 MEDALIST AVE
LAFAYETTE LA
70506-7503
US

V. Phone/Fax

Practice location:
  • Phone: 561-715-7455
  • Fax:
Mailing address:
  • Phone: 561-715-7455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: BRYEE SHEPARD
Title or Position: MEMBER
Credential: RD
Phone: 561-715-7455