Provider Demographics
NPI:1841474418
Name:BOOST COLLABORATIVE
Entity type:Organization
Organization Name:BOOST COLLABORATIVE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:C
Authorized Official - Last Name:HOYLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-332-6561
Mailing Address - Street 1:1235 SE PROFESSIONAL MALL BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5437
Mailing Address - Country:US
Mailing Address - Phone:509-332-6561
Mailing Address - Fax:509-332-3838
Practice Address - Street 1:115 NW STATE STREET
Practice Address - Street 2:SUITE 106
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-2616
Practice Address - Country:US
Practice Address - Phone:509-332-4420
Practice Address - Fax:509-339-2399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600 082 939251V00000X
251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable