Provider Demographics
NPI:1023068459
Name:BAYOU LA BATRE AREA HEALTH DEVELOPMENT BOARD, INC.
Entity type:Organization
Organization Name:BAYOU LA BATRE AREA HEALTH DEVELOPMENT BOARD, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:251-824-2174
Mailing Address - Street 1:P.O. BOX 415
Mailing Address - Street 2:7777 HWY 43 NORTH
Mailing Address - City:MC INTOSH
Mailing Address - State:AL
Mailing Address - Zip Code:36553-0415
Mailing Address - Country:US
Mailing Address - Phone:251-944-2842
Mailing Address - Fax:251-944-8070
Practice Address - Street 1:7777 HIGHWAY 43 NORTH
Practice Address - Street 2:
Practice Address - City:MCINTOSH
Practice Address - State:AL
Practice Address - Zip Code:36553-0415
Practice Address - Country:US
Practice Address - Phone:251-944-2842
Practice Address - Fax:251-944-8070
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAYOU LA BATRE AREA HEALTH DEVELOPMENT BOARD, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-10
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPHL L6503261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL630002015Medicaid
AL01DO692409OtherCLIA
AL630000015Medicaid
AL630002015Medicaid
AL01DO692409OtherCLIA
AL630000015Medicaid
AL011832Medicare Oscar/Certification