Provider Demographics
NPI:1588677454
Name:BAYOU ORTHOTIC AND PROSTHETIC CENTER LLC
Entity Type:Organization
Organization Name:BAYOU ORTHOTIC AND PROSTHETIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:BORDELON
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:504-341-1331
Mailing Address - Street 1:3717 VONNIE DR
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-2354
Mailing Address - Country:US
Mailing Address - Phone:504-341-1331
Mailing Address - Fax:504-341-1341
Practice Address - Street 1:3717 VONNIE DR
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:LA
Practice Address - Zip Code:70058-2354
Practice Address - Country:US
Practice Address - Phone:504-341-1331
Practice Address - Fax:504-341-1341
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAYOU ORTHOTIC AND PROSTHETIC CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-14
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1011690Medicaid
LAG0464OtherBLUE CROSS BLUE SHIELD
LA4304040002Medicare NSC