Provider Demographics
NPI:1093074312
Name:RAQUEL BOUTON
Entity Type:Organization
Organization Name:RAQUEL BOUTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:RAQUEL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BOUTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-828-2882
Mailing Address - Street 1:2 DOMINO WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT SINAI
Mailing Address - State:NY
Mailing Address - Zip Code:11766-2715
Mailing Address - Country:US
Mailing Address - Phone:631-828-2882
Mailing Address - Fax:
Practice Address - Street 1:2 DOMINO WAY
Practice Address - Street 2:
Practice Address - City:MOUNT SINAI
Practice Address - State:NY
Practice Address - Zip Code:11766-2715
Practice Address - Country:US
Practice Address - Phone:631-828-2882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10303300251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)