Healthcare Provider Details

I. General information

NPI: 1225639180
Provider Name (Legal Business Name): LUIS L BOULART
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2020
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8260 W FLAGLER ST STE 2I
MIAMI FL
33144-2069
US

IV. Provider business mailing address

9725 NW 117TH AVE STE 200
MEDLEY FL
33178-1260
US

V. Phone/Fax

Practice location:
  • Phone: 786-715-9183
  • Fax:
Mailing address:
  • Phone: 954-514-9360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11008799
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: