Provider Demographics
NPI:1821310020
Name:BLUE BAYOU SERVICES GROUP INC
Entity Type:Organization
Organization Name:BLUE BAYOU SERVICES GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:MANAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-339-2302
Mailing Address - Street 1:6221 S CLAIBORNE AVE
Mailing Address - Street 2:STE B614
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70125-4142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6221 S CLAIBORNE AVE
Practice Address - Street 2:STE B614
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70125-4142
Practice Address - Country:US
Practice Address - Phone:504-339-2302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06583R207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty