Provider Demographics
NPI:1114996865
Name:BAYOUCLINIC, INC.
Entity Type:Organization
Organization Name:BAYOUCLINIC, INC.
Other - Org Name:BAYOU LA BATRE RURAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:H
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-824-4985
Mailing Address - Street 1:13220 N WINTZELL AVE
Mailing Address - Street 2:
Mailing Address - City:BAYOU LA BATRE
Mailing Address - State:AL
Mailing Address - Zip Code:36509-2142
Mailing Address - Country:US
Mailing Address - Phone:251-824-4985
Mailing Address - Fax:251-824-4990
Practice Address - Street 1:13833 TAPIA AVE
Practice Address - Street 2:
Practice Address - City:BAYOU LA BATRE
Practice Address - State:AL
Practice Address - Zip Code:36509-2515
Practice Address - Country:US
Practice Address - Phone:251-824-4985
Practice Address - Fax:251-824-4990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529932897Medicaid
AL541003845Medicaid
AL541003845Medicaid