Provider Demographics
NPI:1013782804
Name:MSP BOONE CLINIC, PLLC
Entity Type:Organization
Organization Name:MSP BOONE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:TENLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:828-265-3668
Mailing Address - Street 1:610 STATE FARM RD STE C
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-4713
Mailing Address - Country:US
Mailing Address - Phone:828-265-3668
Mailing Address - Fax:
Practice Address - Street 1:200 HOSPITAL AVE FL 3
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:NC
Practice Address - Zip Code:28640-9244
Practice Address - Country:US
Practice Address - Phone:828-265-9662
Practice Address - Fax:828-252-2272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-21
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty