Provider Demographics
NPI:1144078254
Name:BAYOU ORTHOTIC AND PROSTHETIC CENTER LLC
Entity type:Organization
Organization Name:BAYOU ORTHOTIC AND PROSTHETIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARA
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:504-833-7339
Mailing Address - Street 1:611 RIVER HIGHLANDS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-8908
Mailing Address - Country:US
Mailing Address - Phone:985-302-3818
Mailing Address - Fax:504-833-7559
Practice Address - Street 1:611 RIVER HIGHLANDS BLVD STE A
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-8908
Practice Address - Country:US
Practice Address - Phone:985-302-3818
Practice Address - Fax:504-833-7559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier