Provider Demographics
NPI:1659389179
Name:BOSTEN CHIROPRACTIC A CORPORATION
Entity Type:Organization
Organization Name:BOSTEN CHIROPRACTIC A CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:DORENE
Authorized Official - Last Name:CLEVELAND-BOSTEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:310-559-6900
Mailing Address - Street 1:3283 MOTOR AVENUE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034
Mailing Address - Country:US
Mailing Address - Phone:310-559-6900
Mailing Address - Fax:310-836-8664
Practice Address - Street 1:3283 MOTOR AVENUE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034
Practice Address - Country:US
Practice Address - Phone:310-559-6900
Practice Address - Fax:310-836-8664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC17611111N00000X
111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WDC17611AOtherP PIN
WDC17611AOtherP PIN
T18577Medicare UPIN