Provider Demographics
NPI:1205281938
Name:BOULLON REHABILITATION CENTER LLC
Entity type:Organization
Organization Name:BOULLON REHABILITATION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-360-6577
Mailing Address - Street 1:2450 SW 137TH AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-8802
Mailing Address - Country:US
Mailing Address - Phone:786-360-6577
Mailing Address - Fax:786-636-6964
Practice Address - Street 1:2450 SW 137TH AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-8802
Practice Address - Country:US
Practice Address - Phone:786-360-6577
Practice Address - Fax:786-636-6964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC12163261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation