Provider Demographics
NPI:1598132433
Name:BOISSEY, TIM
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:BOISSEY
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 1:2041 N COMMONWEALTH AVE APT 103
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-2840
Mailing Address - Country:US
Mailing Address - Phone:336-575-9371
Mailing Address - Fax:
Practice Address - Street 1:2041 N COMMONWEALTH AVE APT 103
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-2840
Practice Address - Country:US
Practice Address - Phone:336-575-9371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist