1053824805 NPI number — MR. DANIEL BOULANGER ATC, CES, PES

Table of content: MR. DANIEL BOULANGER ATC, CES, PES (NPI 1053824805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053824805 NPI number — MR. DANIEL BOULANGER ATC, CES, PES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOULANGER
Provider First Name:
DANIEL
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
ATC, CES, PES
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:
1053824805
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
37 GARDEN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02915-3023
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-473-5733
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1762 LOUISQUISSET PIKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02865
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-333-7000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/14/2017

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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