Provider Demographics
NPI:1790701407
Name:BOSHEARS, SANDRA ELLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:ELLEN
Last Name:BOSHEARS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35191 YUCAIPA BLVD
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399
Mailing Address - Country:US
Mailing Address - Phone:909-790-5005
Mailing Address - Fax:909-790-5009
Practice Address - Street 1:35191 YUCAIPA BLVD
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399
Practice Address - Country:US
Practice Address - Phone:909-790-5005
Practice Address - Fax:909-790-5009
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27016111N00000X
CADC0270160111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGDC000570Medicaid
CAZZZ22436ZMedicare PIN