Provider Demographics
NPI:1639132061
Name:BOULLION, JAMES LARRY (PT)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:LARRY
Last Name:BOULLION
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 1:1432 S COLLEGE RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2912
Mailing Address - Country:US
Mailing Address - Phone:337-232-7080
Mailing Address - Fax:337-237-2517
Practice Address - Street 1:1432 S COLLEGE RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2912
Practice Address - Country:US
Practice Address - Phone:337-232-7080
Practice Address - Fax:337-237-2517
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPT00056225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5X921Medicare ID - Type UnspecifiedMEDICARE NUMBER