| Organization Name: | BLUE BAYOU SERVICE INC |
| NPI Number: | 1144577305 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | WILLIAM BRONSON (CEO) |
| Mailing Address: | 1310 Papin St Saint Louis |
| State: | MO US |
| Postal Code: | 631033132 |
| Phone Number: | 3145021300 |
| Fax Number: | |
| NPI Enumeration Date: | 08/07/2012 |
| NPI Last Update Date: | 09/18/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 12345 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MO |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |