Provider Demographics
NPI:1114177698
Name:BOUDREAUX, DON
Entity Type:Individual
Prefix:
First Name:DON
Middle Name:
Last Name:BOUDREAUX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8420 BUCKLAND ST APT 2
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-2874
Mailing Address - Country:US
Mailing Address - Phone:760-470-4089
Mailing Address - Fax:
Practice Address - Street 1:8420 BUCKLAND ST APT 2
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-2874
Practice Address - Country:US
Practice Address - Phone:760-470-4089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-22
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN174892164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEPS014720Medicaid
CARVN003060Medicaid