Provider Demographics
NPI:1275182487
Name:MA BO INC
Entity Type:Organization
Organization Name:MA BO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAITLIN
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:CACCIATORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-485-5055
Mailing Address - Street 1:522 E 100 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1905
Mailing Address - Country:US
Mailing Address - Phone:801-485-5055
Mailing Address - Fax:801-467-3296
Practice Address - Street 1:522 E 100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1905
Practice Address - Country:US
Practice Address - Phone:801-485-5055
Practice Address - Fax:801-467-3296
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MA BO INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty