Provider Demographics
NPI:1174667091
Name:BOONE, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:BOONE
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 1:2870 N TOWNE AVE
Mailing Address - Street 2:APT 208
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2057
Mailing Address - Country:US
Mailing Address - Phone:909-626-9936
Mailing Address - Fax:
Practice Address - Street 1:1827 ATLANTA AVE
Practice Address - Street 2:D-1
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-7419
Practice Address - Country:US
Practice Address - Phone:951-955-2105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)