Provider Demographics
NPI:1477780179
Name:BOSWELL, RANDY EUGENE (MA, ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:EUGENE
Last Name:BOSWELL
Suffix:
Gender:M
Credentials:MA, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W GARDEN AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2161
Mailing Address - Country:US
Mailing Address - Phone:208-769-3217
Mailing Address - Fax:208-769-7779
Practice Address - Street 1:1000 W GARDEN AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2161
Practice Address - Country:US
Practice Address - Phone:208-769-3217
Practice Address - Fax:208-769-7779
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-19
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer