Provider Demographics
NPI:1750309696
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:504-833-7339
Mailing Address - Street 1:400 N CAUSEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-5338
Mailing Address - Country:US
Mailing Address - Phone:504-833-7339
Mailing Address - Fax:504-833-7559
Practice Address - Street 1:400 N CAUSEWAY BLVD
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-5338
Practice Address - Country:US
Practice Address - Phone:504-833-7339
Practice Address - Fax:504-833-7559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1103284Medicaid
LAH6513OtherBLUE CROSS BLUE SHIELD OF LA
LA1103284Medicaid