Provider Demographics
NPI:1700243300
Name:THE BOUGAINVILLA HOUSE, INC.
Entity Type:Organization
Organization Name:THE BOUGAINVILLA HOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KELI
Authorized Official - Middle Name:
Authorized Official - Last Name:KORNMILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-672-8345
Mailing Address - Street 1:1721 SE 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2515
Mailing Address - Country:US
Mailing Address - Phone:954-764-7337
Mailing Address - Fax:954-764-6283
Practice Address - Street 1:1727 SE 4TH AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2515
Practice Address - Country:US
Practice Address - Phone:954-764-7337
Practice Address - Fax:954-764-6283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-27
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder