Provider Demographics
NPI:1558947499
Name:BOUTIQ MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:BOUTIQ MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BUCKALEW
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-C
Authorized Official - Phone:407-777-2449
Mailing Address - Street 1:1815 GERDA TER
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5934
Mailing Address - Country:US
Mailing Address - Phone:407-446-5425
Mailing Address - Fax:
Practice Address - Street 1:1430 N MILLS AVE STE 120
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1877
Practice Address - Country:US
Practice Address - Phone:407-777-2449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-22
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care