Healthcare Provider Details

I. General information

NPI: 1871550533
Provider Name (Legal Business Name): RICHARD PAUL BOUDREAU CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 03/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E WOOD ST
SPARTANBURG SC
29303-3040
US

IV. Provider business mailing address

PO BOX 277723
ATLANTA GA
30384-7723
US

V. Phone/Fax

Practice location:
  • Phone: 864-560-6122
  • Fax: 864-560-6276
Mailing address:
  • Phone: 864-560-4123
  • Fax: 864-560-4023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR32177
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number352
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: