Provider Demographics
NPI:1447295829
Name:BIENVILLE DIALYSIS CENTER INC
Entity type:Organization
Organization Name:BIENVILLE DIALYSIS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUIDROZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-780-1422
Mailing Address - Street 1:4424 CONLIN ST
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2147
Mailing Address - Country:US
Mailing Address - Phone:504-780-1422
Mailing Address - Fax:
Practice Address - Street 1:3333 BIENVILLE ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-5301
Practice Address - Country:US
Practice Address - Phone:504-822-6336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA100261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1343005Medicaid
LA34514OtherBLUE CROSS BLUE SHIELD LA
LA34514OtherBLUE CROSS BLUE SHIELD LA