Provider Demographics
NPI:1134953045
Name:FRIEND OF BOON
Entity type:Organization
Organization Name:FRIEND OF BOON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SIDNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-672-6153
Mailing Address - Street 1:500 COCHRANE AVE
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5621
Mailing Address - Country:US
Mailing Address - Phone:707-672-6153
Mailing Address - Fax:
Practice Address - Street 1:527 S STATE ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4910
Practice Address - Country:US
Practice Address - Phone:707-672-6153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-02
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care
No251300000XAgenciesLocal Education Agency (LEA)
No253Z00000XAgenciesIn Home Supportive Care
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)