Provider Demographics
NPI:1275729246
Name:BAYOU LA BATRE AREA HEALTH DEVELOPMENT BOARD, INC.
Entity Type:Organization
Organization Name:BAYOU LA BATRE AREA HEALTH DEVELOPMENT BOARD, INC.
Other - Org Name:DURABLE MEDICAL EQUIPMENT DIVISION
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:251-824-2174
Mailing Address - Street 1:PO BOX 769
Mailing Address - Street 2:
Mailing Address - City:BAYOU LA BATRE
Mailing Address - State:AL
Mailing Address - Zip Code:36509-0769
Mailing Address - Country:US
Mailing Address - Phone:251-824-2174
Mailing Address - Fax:251-824-3444
Practice Address - Street 1:12701 PADGETT SWITCH RD
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:AL
Practice Address - Zip Code:36544-4011
Practice Address - Country:US
Practice Address - Phone:251-824-2174
Practice Address - Fax:251-824-3444
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOSTELLAR MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-24
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALN/A261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009998450Medicaid
AL4375120001Medicare PIN