Provider Demographics
NPI:1003148081
Name:JENNIFER R. BOOZER, D.O., INC.
Entity Type:Organization
Organization Name:JENNIFER R. BOOZER, D.O., INC.
Other - Org Name:GRANITE CREEK FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:BOOZER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-450-1571
Mailing Address - Street 1:1601 MONTE VISTA AVE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-2962
Mailing Address - Country:US
Mailing Address - Phone:909-450-1571
Mailing Address - Fax:909-579-0100
Practice Address - Street 1:1601 MONTE VISTA AVE
Practice Address - Street 2:SUITE 260
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-2962
Practice Address - Country:US
Practice Address - Phone:909-450-1571
Practice Address - Fax:909-579-0100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2OA8927261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care