Provider Demographics
NPI:1811133093
Name:BAYOU STATE THERAPY
Entity type:Organization
Organization Name:BAYOU STATE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:SOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:318-219-7737
Mailing Address - Street 1:457 ASHLEY RIDGE BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7229
Mailing Address - Country:US
Mailing Address - Phone:318-219-7737
Mailing Address - Fax:318-219-7739
Practice Address - Street 1:457 ASHLEY RIDGE BLVD STE B
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-7229
Practice Address - Country:US
Practice Address - Phone:318-219-7737
Practice Address - Fax:318-219-7739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-18
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03183261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5DH36Medicare PIN