1558645572 NPI number — JONATHAN BOUTNI PT

Table of content: JONATHAN BOUTNI PT (NPI 1558645572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558645572 NPI number — JONATHAN BOUTNI PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUTNI
Provider First Name:
JONATHAN
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:
1558645572
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O BOX 32008
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLINT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-230-0338
Provider Business Mailing Address Fax Number:
810-715-5005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10293 DIXIE HIGHWAY
Provider Second Line Business Practice Location Address:
SUITE 0
Provider Business Practice Location Address City Name:
HOLLY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-771-7686
Provider Business Practice Location Address Fax Number:
810-771-7685
Provider Enumeration Date:
10/10/2011

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: 225100000X , with the licence number:  5501015725 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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