Provider Demographics
NPI:1932397882
Name:BLUEBONNET FAMILY CLINIC, LLC
Entity Type:Organization
Organization Name:BLUEBONNET FAMILY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARYKUTTY
Authorized Official - Middle Name:J
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-757-6031
Mailing Address - Street 1:9241 BLUEBONNET BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-2808
Mailing Address - Country:US
Mailing Address - Phone:225-757-6031
Mailing Address - Fax:225-757-6035
Practice Address - Street 1:9241 BLUEBONNET BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-2808
Practice Address - Country:US
Practice Address - Phone:225-757-6031
Practice Address - Fax:225-757-6035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022386261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1676471Medicaid
LAG24406Medicare UPIN
LA5CQ91Medicare PIN