1205266814 NPI number — DAVID BOUY PT

Table of content: DAVID BOUY PT (NPI 1205266814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205266814 NPI number — DAVID BOUY PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUY
Provider First Name:
DAVID
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205266814
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1125
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HACKENSACK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07602-1125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-560-9406
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 BANTA PL
Provider Second Line Business Practice Location Address:
STE 111
Provider Business Practice Location Address City Name:
HACKENSACK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07601-5606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-560-9406
Provider Business Practice Location Address Fax Number:
201-334-9815
Provider Enumeration Date:
11/18/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  40QA01501200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)