Provider Demographics
NPI:1134304330
Name:BAYOU HOME BUREAU
Entity Type:Organization
Organization Name:BAYOU HOME BUREAU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUANETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:318-556-0043
Mailing Address - Street 1:8057 WILLIARD RD
Mailing Address - Street 2:PO BOX 561
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-8939
Mailing Address - Country:US
Mailing Address - Phone:318-556-0043
Mailing Address - Fax:318-556-3633
Practice Address - Street 1:8057 WILLIARD RD
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-8939
Practice Address - Country:US
Practice Address - Phone:318-556-0043
Practice Address - Fax:318-556-3633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPCA8246251T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1564761Medicaid
LA1171506Medicaid