1750445292 NPI number — BOULEVARD HEALTH CARE PROGRAM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750445292 NPI number — BOULEVARD HEALTH CARE PROGRAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOULEVARD HEALTH CARE PROGRAM
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1750445292
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8492
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAYAMON
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00960-8492
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-784-0148
Provider Business Mailing Address Fax Number:
787-784-0148

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
URB LEVITTOWN
Provider Second Line Business Practice Location Address:
P1449 AVE. BOULEVARD
Provider Business Practice Location Address City Name:
TOA BAJA
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-784-0148
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GONZALEZ ROMAN
Authorized Official First Name:
LUISA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICAL THERAPIST
Authorized Official Telephone Number:
787-784-0148

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  414 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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