Provider Demographics
NPI:1740228709
Name:BOISTON, CLYDE FRANCIS (PT, OCS)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:FRANCIS
Last Name:BOISTON
Suffix:
Gender:M
Credentials:PT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29650 BRADLEY RD
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92586-6521
Mailing Address - Country:US
Mailing Address - Phone:951-672-0455
Mailing Address - Fax:
Practice Address - Street 1:29650 BRADLEY RD
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586-6521
Practice Address - Country:US
Practice Address - Phone:951-672-0455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 23165225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0147050Medicaid
CAPT0147050Medicaid