Healthcare Provider Details

I. General information

NPI: 1417901190
Provider Name (Legal Business Name): DAVID J BOUCHER PT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 WATERMAN AVE
E PROVIDENCE RI
02914-1314
US

IV. Provider business mailing address

31 OLD ROUTE 7 ATTN: CREDENTIALING DEPT
BROOKFIELD CT
06804-1714
US

V. Phone/Fax

Practice location:
  • Phone: 401-434-1773
  • Fax: 401-435-0500
Mailing address:
  • Phone: 203-740-0020
  • Fax: 203-775-0238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number01754
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: