Provider Demographics
NPI:1699055475
Name:GULF COAST BRAIN SPORT & SPINE LLC
Entity type:Organization
Organization Name:GULF COAST BRAIN SPORT & SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:J
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-237-1430
Mailing Address - Street 1:PO BOX 2013
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70470-2013
Mailing Address - Country:US
Mailing Address - Phone:504-237-1430
Mailing Address - Fax:
Practice Address - Street 1:1331 OCHSNER BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-8177
Practice Address - Country:US
Practice Address - Phone:985-234-0490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2013-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14743R208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty