# GULF COAST BRAIN SPORT & SPINE LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1699055475
- **Authorized official:** DR. BEAU J BAGLEY MD (OWNER)
- **Authorized official phone:** (504) 237-1430

## Contact information

- **Practice address:** 1331 OCHSNER BLVD, SUITE 100, COVINGTON, LA 70433-8177
- **Practice address phone:** (985) 234-0490
- **Mailing address:** PO BOX 2013, MANDEVILLE, LA 70470-2013
- **Mailing address phone:** (504) 237-1430

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208100000X | Physical Medicine & Rehabilitation Physician | 14743R | LA | Yes |

## Other

- **Enumeration date:** 08/24/2011
- **Last updated:** 03/30/2013