Provider Demographics
NPI:1841280328
Name:BOANERGES
Entity type:Organization
Organization Name:BOANERGES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-658-3865
Mailing Address - Street 1:PO BOX 402
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-0402
Mailing Address - Country:US
Mailing Address - Phone:810-658-3865
Mailing Address - Fax:810-658-3865
Practice Address - Street 1:320 S STATE RD
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1510
Practice Address - Country:US
Practice Address - Phone:810-658-3865
Practice Address - Fax:810-658-3865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0890343416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4115526Medicaid
MI590D40002OtherBCBS
MI4115526Medicaid