Provider Demographics
NPI:1942393699
Name:BLUEBONNET IMAGING CENTER, LLC
Entity Type:Organization
Organization Name:BLUEBONNET IMAGING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAUTHIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-930-0060
Mailing Address - Street 1:PO BOX 14149
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70898-4149
Mailing Address - Country:US
Mailing Address - Phone:225-298-3223
Mailing Address - Fax:225-298-5474
Practice Address - Street 1:4570 BLUEBONNET BLVD.
Practice Address - Street 2:SUITE B
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809
Practice Address - Country:US
Practice Address - Phone:225-298-3223
Practice Address - Fax:225-298-5474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1025666Medicaid
LA=========OtherTAX ID
LA5DA31Medicare PIN
LA1025666Medicaid