Healthcare Provider Details

I. General information

NPI: 1508491283
Provider Name (Legal Business Name): ANTHONY BAHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9677 FLORIDA BLVD
WALKER LA
70785-7205
US

IV. Provider business mailing address

50296 RIVERS RD
TICKFAW LA
70466-6017
US

V. Phone/Fax

Practice location:
  • Phone: 225-664-4825
  • Fax:
Mailing address:
  • Phone: 985-981-9697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number306002
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: