Provider Demographics
NPI:1912109067
Name:BOYD, WILLIE EDWARD
Entity Type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:EDWARD
Last Name:BOYD
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 1:315 EAST CLIFFWOOD
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75603
Mailing Address - Country:US
Mailing Address - Phone:903-643-2129
Mailing Address - Fax:903-643-0307
Practice Address - Street 1:315 EAST CLIFFWOOD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75603
Practice Address - Country:US
Practice Address - Phone:903-643-2129
Practice Address - Fax:903-643-0307
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2014-12-29
Deactivation Date:2008-01-22
Deactivation Code:
Reactivation Date:2014-12-29
Provider Licenses
StateLicense IDTaxonomies
TX310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility