Healthcare Provider Details

I. General information

NPI: 1689605834
Provider Name (Legal Business Name): BIENVILLE ORTHOPAEDIC SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 EAST LAKE BLVD. SUITE 201
VANCLEAVE MS
39565-6771
US

IV. Provider business mailing address

6300 EAST LAKE BLVD. SUITE 301
VANCLEAVE MS
39565-6771
US

V. Phone/Fax

Practice location:
  • Phone: 228-230-2663
  • Fax: 228-206-1192
Mailing address:
  • Phone: 228-230-2663
  • Fax: 228-206-6398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: LEE BOND
Title or Position: CEO
Credential:
Phone: 228-230-2663