Provider Demographics
NPI:1467944173
Name:BOURET, VIRGINIA MILAGROS
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:MILAGROS
Last Name:BOURET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 S RIO GRANDE AVE APT 210B
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-1114
Mailing Address - Country:US
Mailing Address - Phone:407-501-1135
Mailing Address - Fax:
Practice Address - Street 1:4444 S RIO GRANDE AVE APT 210B
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32839-1114
Practice Address - Country:US
Practice Address - Phone:407-501-1135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB63087355680OtherDRIVERS LICENSE