Healthcare Provider Details

I. General information

NPI: 1114937000
Provider Name (Legal Business Name): EARL DOUGLAS BOURGOYNE BSCPO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

617 RIO HONDO RD NE
RIO RANCHO NM
87144-4717
US

V. Phone/Fax

Practice location:
  • Phone: 505-256-2756
  • Fax:
Mailing address:
  • Phone: 505-891-9210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: