Provider Demographics
NPI:1245724830
Name:BOULGARIDES, LOIS
Entity type:Individual
Prefix:
First Name:LOIS
Middle Name:
Last Name:BOULGARIDES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 ISLE ROYALE LN
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-6617
Mailing Address - Country:US
Mailing Address - Phone:530-400-2589
Mailing Address - Fax:
Practice Address - Street 1:500 QUINTANA RD
Practice Address - Street 2:
Practice Address - City:MORRO BAY
Practice Address - State:CA
Practice Address - Zip Code:93442-1938
Practice Address - Country:US
Practice Address - Phone:805-772-7358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8355225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist