Provider Demographics
NPI:1093944209
Name:BOSWELL, LA,VALLE
Entity Type:Individual
Prefix:
First Name:LA,VALLE
Middle Name:
Last Name:BOSWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 ABS/SG
Mailing Address - Street 2:UNIT 6870 BOX 14,
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09821
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:425 ABS/SG
Practice Address - Street 2:UNIT 6870 BOX 14,
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09821
Practice Address - Country:US
Practice Address - Phone:032-675-3236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians