Provider Demographics
NPI:1417712597
Name:PATRICK, BOSE
Entity Type:Individual
Prefix:
First Name:BOSE
Middle Name:
Last Name:PATRICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BOSE
Other - Middle Name:
Other - Last Name:PATRICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:N/A
Mailing Address - Street 1:2917 BOULDER DR
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-4154
Mailing Address - Country:US
Mailing Address - Phone:151-542-1650
Mailing Address - Fax:
Practice Address - Street 1:2917 BOULDER DR
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-4154
Practice Address - Country:US
Practice Address - Phone:151-542-1650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-16
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician