Provider Demographics
NPI:1588936702
Name:JOSEPH B BOUCREE JR INC
Entity type:Organization
Organization Name:JOSEPH B BOUCREE JR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRONT OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:RYALS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-205-3456
Mailing Address - Street 1:1570 LINDBERG DR STE 8
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-8084
Mailing Address - Country:US
Mailing Address - Phone:985-205-3456
Mailing Address - Fax:985-288-0047
Practice Address - Street 1:1570 LINDBERG DR STE 8
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-8084
Practice Address - Country:US
Practice Address - Phone:985-205-3456
Practice Address - Fax:985-288-0047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-03
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020305207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5DW76Medicare PIN