Provider Demographics
NPI:1891877155
Name:BOSHMAN, KELLY ALEXANDER (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ALEXANDER
Last Name:BOSHMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32221 CAMINO CAPISTRANO
Mailing Address - Street 2:SUITE B106
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-3721
Mailing Address - Country:US
Mailing Address - Phone:949-493-4141
Mailing Address - Fax:
Practice Address - Street 1:32221 CAMINO CAPISTRANO
Practice Address - Street 2:SUITE B106
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3721
Practice Address - Country:US
Practice Address - Phone:949-493-4141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13945111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor