Provider Demographics
NPI:1932978517
Name:BOONDOCK EXPRESS
Entity Type:Organization
Organization Name:BOONDOCK EXPRESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HASAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:ABDUSHAHID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-229-8303
Mailing Address - Street 1:9927 JEANETTE CIR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-2129
Mailing Address - Country:US
Mailing Address - Phone:980-229-8303
Mailing Address - Fax:
Practice Address - Street 1:9927 JEANETTE CIR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-2129
Practice Address - Country:US
Practice Address - Phone:980-229-8303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-25
Last Update Date:2023-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation TherapistGroup - Multi-Specialty
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No251X00000XAgenciesSupports BrokerageGroup - Multi-Specialty
No372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Multi-Specialty
No385HR2050XRespite Care FacilityRespite CareRespite Care CampGroup - Multi-Specialty