=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114371044
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOULEVARD OPERATING INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2016
-----------------------------------------------------
Last Update Date | 04/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 122-11 HILLSIDE AVE
-----------------------------------------------------
City | JAMAICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-846-4091
-----------------------------------------------------
Fax | 718-805-0166
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12211 HILLSIDE AVE
-----------------------------------------------------
City | JAMAICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11418-1817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-846-4091
-----------------------------------------------------
Fax | 718-805-0166
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. TONY FERRO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 178-846-4091
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 344600000X
-----------------------------------------------------
Taxonomy Name | Taxi
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------