Provider Demographics
NPI:1285014191
Name:BOUDREAU, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BOUDREAU
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 1:515 COLUMBIA AVE STE 515
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1209
Mailing Address - Country:US
Mailing Address - Phone:213-553-1800
Mailing Address - Fax:213-368-1366
Practice Address - Street 1:515 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1209
Practice Address - Country:US
Practice Address - Phone:213-368-1888
Practice Address - Fax:213-368-6888
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker