Provider Demographics
NPI:1588604649
Name:BOURLAI, KEVIN J (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:BOURLAI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20403 BUTTERMILK
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-9490
Mailing Address - Country:US
Mailing Address - Phone:808-283-4139
Mailing Address - Fax:
Practice Address - Street 1:730 SW BONNETT WAY
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1192
Practice Address - Country:US
Practice Address - Phone:808-283-4139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT-1393225100000X
OR5882225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500645456Medicaid
HI00F0051570OtherHMSA BILLING NUMBER
HI24488102Medicaid
HI24488102Medicaid
ORR163883Medicare PIN