Provider Demographics
NPI:1174298798
Name:BOSWELL, DIMARCUS SANTORI JR
Entity Type:Individual
Prefix:
First Name:DIMARCUS
Middle Name:SANTORI
Last Name:BOSWELL
Suffix:JR
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 1:603 APPLE ST
Mailing Address - Street 2:
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155-1908
Mailing Address - Country:US
Mailing Address - Phone:304-904-0808
Mailing Address - Fax:
Practice Address - Street 1:603 APPLE ST
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-1908
Practice Address - Country:US
Practice Address - Phone:304-904-0808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1356607394Medicaid
WV1821206228Medicaid
WV1255523494Medicaid