Healthcare Provider Details

I. General information

NPI: 1891870929
Provider Name (Legal Business Name): LA BODEGA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1579 HIGHWAY 51
PONCHATOULA LA
70454-6374
US

IV. Provider business mailing address

327 W 21ST AVE
COVINGTON LA
70433-3153
US

V. Phone/Fax

Practice location:
  • Phone: 985-635-6900
  • Fax: 985-635-6936
Mailing address:
  • Phone: 985-635-6900
  • Fax: 985-635-6936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number922
License Number StateLA

VIII. Authorized Official

Name: MILTON R MIZE
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 985-635-6900