Provider Demographics
NPI:1982218517
Name:BOERNE MENS CLINIC
Entity Type:Organization
Organization Name:BOERNE MENS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:WAITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-682-5323
Mailing Address - Street 1:138 TX 46 W
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:76008-3644
Mailing Address - Country:US
Mailing Address - Phone:830-446-5051
Mailing Address - Fax:
Practice Address - Street 1:138 TX-46
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006
Practice Address - Country:US
Practice Address - Phone:713-551-3455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-01
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1477547099OtherDR. LIVINGSTON, MD NPI