Provider Demographics
NPI:1649805409
Name:BOYETTE, DALIS
Entity type:Individual
Prefix:
First Name:DALIS
Middle Name:
Last Name:BOYETTE
Suffix:
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 1:3100 BEUTEL ROAD
Mailing Address - Street 2:
Mailing Address - City:LORENA
Mailing Address - State:TX
Mailing Address - Zip Code:76655
Mailing Address - Country:US
Mailing Address - Phone:979-587-5930
Mailing Address - Fax:
Practice Address - Street 1:1500 S UNIVERSITY PARKS DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76706-1731
Practice Address - Country:US
Practice Address - Phone:254-405-5856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT56672255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer