Healthcare Provider Details

I. General information

NPI: 1669564779
Provider Name (Legal Business Name): PAUL FRANCIS BOURQUE CO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 ORANGE AVE STE B
WINTER PARK FL
32789-4918
US

IV. Provider business mailing address

2704 STONE AVE
DELAND FL
32720-3803
US

V. Phone/Fax

Practice location:
  • Phone: 407-740-7772
  • Fax: 407-539-1791
Mailing address:
  • Phone: 386-738-2833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberORT6
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: