Provider Demographics
NPI:1275856270
Name:THE MEDICAL SPA OF BATON ROUGE
Entity Type:Organization
Organization Name:THE MEDICAL SPA OF BATON ROUGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENYATTA
Authorized Official - Middle Name:DAYATRA
Authorized Official - Last Name:SHAMLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-216-7885
Mailing Address - Street 1:7150 JEFFERSON HWY
Mailing Address - Street 2:SUITE 530
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-8128
Mailing Address - Country:US
Mailing Address - Phone:225-216-7885
Mailing Address - Fax:
Practice Address - Street 1:7150 JEFFERSON HWY
Practice Address - Street 2:SUITE 530
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-8128
Practice Address - Country:US
Practice Address - Phone:225-216-7885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-04
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA202129207Q00000X
LA025911207R00000X
LA025910207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty