Provider Demographics
NPI:1083854087
Name:BAYOU WELLNESS CENTER, INC.
Entity Type:Organization
Organization Name:BAYOU WELLNESS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-218-9556
Mailing Address - Street 1:PO BOX 1550
Mailing Address - Street 2:27403 HWY 190, SUITE B
Mailing Address - City:LACOMBE
Mailing Address - State:LA
Mailing Address - Zip Code:70445-1550
Mailing Address - Country:US
Mailing Address - Phone:985-218-9555
Mailing Address - Fax:985-218-9557
Practice Address - Street 1:27403 HWY 190, SUITE B
Practice Address - Street 2:
Practice Address - City:LACOMBE
Practice Address - State:LA
Practice Address - Zip Code:70445-1550
Practice Address - Country:US
Practice Address - Phone:985-218-9555
Practice Address - Fax:985-218-9557
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAYOU WELLNESS CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-03
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207QS0010X, 208100000X, 2083P0500X
261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA21-33306Medicaid
LA2133306Medicaid
LA194550Medicare PIN
LA21-33306Medicaid
LA2133306Medicaid