Provider Demographics
NPI:1912289224
Name:EAST BAYOU MEDICAL SUPPLY
Entity Type:Organization
Organization Name:EAST BAYOU MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:FENN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:337-269-0136
Mailing Address - Street 1:204 ENERGY PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3816
Mailing Address - Country:US
Mailing Address - Phone:337-269-0136
Mailing Address - Fax:337-233-8525
Practice Address - Street 1:204 ENERGY PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-3816
Practice Address - Country:US
Practice Address - Phone:337-269-0136
Practice Address - Fax:337-233-8525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD200825261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center