Provider Demographics
NPI:1306393236
Name:BOUSTANI, JOSEPH CHARLES
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:CHARLES
Last Name:BOUSTANI
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 1:23855 DAVID DR UNIT 102
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-2904
Mailing Address - Country:US
Mailing Address - Phone:440-723-1371
Mailing Address - Fax:
Practice Address - Street 1:3223 DAISY AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-2110
Practice Address - Country:US
Practice Address - Phone:440-930-8861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400656670807374U00000X
376J00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide