Provider Demographics
NPI:1528762671
Name:BOULEVARD ENT SURGERY CENTER LLC
Entity type:Organization
Organization Name:BOULEVARD ENT SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JANELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:865-427-4040
Mailing Address - Street 1:9300 PARK WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4301
Mailing Address - Country:US
Mailing Address - Phone:865-427-4040
Mailing Address - Fax:865-427-4041
Practice Address - Street 1:9300 PARK WEST BLVD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4301
Practice Address - Country:US
Practice Address - Phone:865-427-4040
Practice Address - Fax:865-427-4041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical