Provider Demographics
NPI:1619747276
Name:BOESE, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BOESE
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 1:2750 E COLLIER RD
Mailing Address - Street 2:
Mailing Address - City:ACAMPO
Mailing Address - State:CA
Mailing Address - Zip Code:95220-9201
Mailing Address - Country:US
Mailing Address - Phone:916-524-3521
Mailing Address - Fax:
Practice Address - Street 1:1330 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3025
Practice Address - Country:US
Practice Address - Phone:916-524-3521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA397005496310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility