Provider Demographics
NPI:1316925282
Name:BOUFFARD, MANUEL (OTR CHT)
Entity type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:
Last Name:BOUFFARD
Suffix:
Gender:M
Credentials:OTR CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3717
Mailing Address - Country:US
Mailing Address - Phone:562-428-3556
Mailing Address - Fax:562-428-3621
Practice Address - Street 1:4010 ORANGE AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-2374
Practice Address - Country:US
Practice Address - Phone:562-428-3556
Practice Address - Fax:562-428-3621
Is Sole Proprietor?:No
Enumeration Date:2006-01-02
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00978225000000X, 225400000X, 225X00000X, 225XH1200X, 225XH1300X, 225XN1300X, 225XP0200X, 225XR0403X
CAOT00978225XE1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No225XE1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistErgonomics
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225XH1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHuman Factors
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225XR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistDriving and Community Mobility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5208580001OtherDMERC
CAZZZ08589ZOtherBLUE SHIELD OF CALIFORNIA
CAZZZ08589ZOtherBLUE SHIELD OF CALIFORNIA
CAOT00978Medicare ID - Type UnspecifiedOCCUPATIONAL THERAPIST