Basic Information
| Provider Information | |||||||||
| NPI: | 1134249592 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOULLY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6021 ROLLING VISTA LOOP | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335274268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137598761 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1513 SUN CITY CENTER PLZ | ||||||||
| Address2: | |||||||||
| City: | SUN CITY CENTER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335735390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136346022 | ||||||||
| FaxNumber: | 8136346053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT18461 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.