Provider Demographics
NPI:1760774814
Name:BOULEVARD FAMILY CLINIC LLC
Entity Type:Organization
Organization Name:BOULEVARD FAMILY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:T
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:CATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-470-1884
Mailing Address - Street 1:3431 S BOULEVARD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5475
Mailing Address - Country:US
Mailing Address - Phone:405-470-1884
Mailing Address - Fax:
Practice Address - Street 1:3431 S BOULEVARD
Practice Address - Street 2:SUITE 109
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5475
Practice Address - Country:US
Practice Address - Phone:405-470-1884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty