Healthcare Provider Details

I. General information

NPI: 1609948009
Provider Name (Legal Business Name): BOULEVARD EAST FAMILY AND OCCUPATIONAL MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 BOWMAN ST SUITE 3
MORRISTOWN TN
37813-3856
US

IV. Provider business mailing address

1443 W MORRIS BLVD SUITE B
MORRISTOWN TN
37813
US

V. Phone/Fax

Practice location:
  • Phone: 423-318-1185
  • Fax: 423-318-1015
Mailing address:
  • Phone: 423-318-1185
  • Fax: 423-318-1015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberMD 0000040290
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License NumberMD0000040290
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberMD0000040290
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberMD0000040290
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code261QM1103X
TaxonomyMilitary Ambulatory Procedure Visits Operational (Transportable) Clinic/Center
License NumberMD0000040290
License Number StateTN
# 6
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDS0000007577
License Number StateTN
# 7
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberMD0000040290
License Number StateTN
# 8
Primary TaxonomyN
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License NumberMD0000040290
License Number StateTN
# 9
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MOSES BENAIAH BENAVIDES
Title or Position: CEO
Credential: MD
Phone: 423-318-1185