Provider Demographics
NPI:1780184408
Name:BOULLION, RENE III
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:
Last Name:BOULLION
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-1212
Mailing Address - Country:US
Mailing Address - Phone:616-897-8473
Mailing Address - Fax:
Practice Address - Street 1:350 N CENTER ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-1212
Practice Address - Country:US
Practice Address - Phone:616-897-8473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist