Provider Demographics
NPI:1134234594
Name:BOLDUC, CHRISTIAN PAUL (PT)
Entity type:Individual
Prefix:MR
First Name:CHRISTIAN
Middle Name:PAUL
Last Name:BOLDUC
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11135 S JOG ROAD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-1817
Mailing Address - Country:US
Mailing Address - Phone:561-752-3820
Mailing Address - Fax:561-752-5788
Practice Address - Street 1:11135 S JOG ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-1817
Practice Address - Country:US
Practice Address - Phone:561-752-3820
Practice Address - Fax:561-752-5788
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11485225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
K4872Medicare ID - Type Unspecified