Provider Demographics
NPI:1821836768
Name:DEVORE, BOSTON HUNTER (PTA)
Entity type:Individual
Prefix:MR
First Name:BOSTON
Middle Name:HUNTER
Last Name:DEVORE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3637 BRIDGEPORT RD
Mailing Address - Street 2:
Mailing Address - City:EDMONTON
Mailing Address - State:KY
Mailing Address - Zip Code:42129-8466
Mailing Address - Country:US
Mailing Address - Phone:270-590-8801
Mailing Address - Fax:
Practice Address - Street 1:109 HOMEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3468
Practice Address - Country:US
Practice Address - Phone:270-651-6126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA04587225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant