Provider Demographics
NPI:1164058798
Name:KENNETH BOYER OD, INC
Entity Type:Organization
Organization Name:KENNETH BOYER OD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR/BILLER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-596-6756
Mailing Address - Street 1:2443 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-3028
Mailing Address - Country:US
Mailing Address - Phone:909-596-6756
Mailing Address - Fax:909-593-0786
Practice Address - Street 1:2443 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-3028
Practice Address - Country:US
Practice Address - Phone:909-596-6756
Practice Address - Fax:909-593-0786
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENNETH BOYER OD, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-03-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD000651Medicaid