Organization
BOULEVARD MEDICAL GROUP, INC.
Active
Other names
Prohealth Physical Medicine
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ROBERT GONZALEZ D.C. (PRESIDENT)
(818) 505-0152
Entity
Organization
Contact information
Practice address
11239 VENTURA BLVD STE 213, STUDIO CITY, CA 91604-3167
(818) 505-0152
(818) 505-0398
Mailing address
11239 VENTURA BLVD STE 213, STUDIO CITY, CA 91604-3167
(818) 505-0152
(818) 505-0398
Taxonomy
Speciality
Code
Description
License number
State
208100000X
Physical Medicine & Rehabilitation Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CB236695
MEDICARE DME PTAN
CA
Enumeration date
09/25/2014
Last updated
10/23/2015
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