Provider Demographics
NPI:1154508703
Name:BROUILLARD, ROBERT E
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:BROUILLARD
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 1:5440 W FRANKLIN RD
Mailing Address - Street 2:STE 100
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-1079
Mailing Address - Country:US
Mailing Address - Phone:208-422-1555
Mailing Address - Fax:
Practice Address - Street 1:5440 W FRANKLIN RD
Practice Address - Street 2:STE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1079
Practice Address - Country:US
Practice Address - Phone:208-422-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-25
Last Update Date:2011-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2323174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist