Provider Demographics
NPI:1841738341
Name:BOULEVARD VAN CITY LLC
Entity Type:Organization
Organization Name:BOULEVARD VAN CITY LLC
Other - Org Name:BOULEVARD VAN CITY & HOME MOBILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:J
Authorized Official - Last Name:SOUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-731-4335
Mailing Address - Street 1:2708 NIAGARA FALLS BLVD
Mailing Address - Street 2:
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14304-4517
Mailing Address - Country:US
Mailing Address - Phone:716-731-4335
Mailing Address - Fax:716-731-4331
Practice Address - Street 1:2708 NIAGARA FALLS BLVD
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14304-4517
Practice Address - Country:US
Practice Address - Phone:716-731-4335
Practice Address - Fax:716-731-4331
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOULEVARD VAN CITY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-03
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171WH0202X, 171WV0202X
NY343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WV0202XOther Service ProvidersContractorVehicle ModificationsGroup - Multi-Specialty
No171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Multi-Specialty
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04082239Medicaid