Provider Demographics
NPI:1760596860
Name:BACK TO LIFE LLC - BEN BOOHER DO
Entity Type:Organization
Organization Name:BACK TO LIFE LLC - BEN BOOHER DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:W
Authorized Official - Last Name:BOOHER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:541-571-8201
Mailing Address - Street 1:PO BOX 53
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-0053
Mailing Address - Country:US
Mailing Address - Phone:541-289-4555
Mailing Address - Fax:541-289-4556
Practice Address - Street 1:4309 W. 27TH PL.
Practice Address - Street 2:SUITE 200
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99338
Practice Address - Country:US
Practice Address - Phone:509-735-5433
Practice Address - Fax:509-735-5435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP1774207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G91800Medicare UPIN