Healthcare Provider Details

I. General information

NPI: 1750445292
Provider Name (Legal Business Name): BOULEVARD HEALTH CARE PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

URB LEVITTOWN P1449 AVE. BOULEVARD
TOA BAJA PR
00949
US

IV. Provider business mailing address

PO BOX 8492
BAYAMON PR
00960-8492
US

V. Phone/Fax

Practice location:
  • Phone: 787-784-0148
  • Fax:
Mailing address:
  • Phone: 787-784-0148
  • Fax: 787-784-0148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number414
License Number StatePR

VIII. Authorized Official

Name: MRS. LUISA GONZALEZ ROMAN
Title or Position: PHYSICAL THERAPIST
Credential:
Phone: 787-784-0148