Provider Demographics
NPI:1376816793
Name:GUY R. BOSWELL,O.D. LLC
Entity Type:Organization
Organization Name:GUY R. BOSWELL,O.D. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GUY
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOSWELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:206-363-9111
Mailing Address - Street 1:3114 NE 125TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-4515
Mailing Address - Country:US
Mailing Address - Phone:206-363-9111
Mailing Address - Fax:
Practice Address - Street 1:3114 NE 125TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-4515
Practice Address - Country:US
Practice Address - Phone:206-363-9111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD 502152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2007879Medicaid