Provider Demographics
NPI: | 1922370857 |
---|---|
Name: | BOESE, BRIAN CLARK (DPT) |
Entity Type: | Individual |
Prefix: | |
First Name: | BRIAN |
Middle Name: | CLARK |
Last Name: | BOESE |
Suffix: | |
Gender: | M |
Credentials: | DPT |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 790 REMINGTON BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | BOLINGBROOK |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60440-4909 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 810-229-6140 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 10415 GRAND RIVER RD STE 300 |
Practice Address - Street 2: | |
Practice Address - City: | BRIGHTON |
Practice Address - State: | MI |
Practice Address - Zip Code: | 48116-6533 |
Practice Address - Country: | US |
Practice Address - Phone: | 810-229-6140 |
Practice Address - Fax: | 810-229-6145 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2012-02-08 |
Last Update Date: | 2018-03-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IA | 004883 | 225100000X |
OR | 60259 | 225100000X |
MI | 5501018260 | 225100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OR | 0349714 | Other | WA L&I |
OR | 500697800 | Medicaid | |
OR | P01740336 | Other | RR MEDICARE |
OR | 0349714 | Other | WA L&I |