Provider Demographics
NPI:1013783232
Name:BOEHM, DOUGLAS EDWARD JR
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:EDWARD
Last Name:BOEHM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 W GRAND LEDGE HWY
Mailing Address - Street 2:
Mailing Address - City:SUNFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48890-9781
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:241 W GRAND LEDGE HWY
Practice Address - Street 2:
Practice Address - City:SUNFIELD
Practice Address - State:MI
Practice Address - Zip Code:48890-9781
Practice Address - Country:US
Practice Address - Phone:517-566-8832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility