Provider Demographics
NPI:1356361091
Name:BOSHEARS, ANDREW (DC)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:BOSHEARS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12132 CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-4331
Mailing Address - Country:US
Mailing Address - Phone:909-790-5005
Mailing Address - Fax:909-790-5009
Practice Address - Street 1:12132 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-4331
Practice Address - Country:US
Practice Address - Phone:909-790-5005
Practice Address - Fax:909-790-5009
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26844111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGDC000570Medicaid
CAGDC000570Medicaid