MEDICARE: MR. BO ERNEST OWENS ATC, CSCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1144328550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BO ERNEST OWENS ATC, CSCS

Provider Business Mailing Address
First Line	:	5349 EUNICE ST
Second Line	:
City	:	ROHNERT PARK
State	:	CA
Zip	:	94928-1822
Country	:	US
Telephone Number	:	707-586-2860
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 E COTATI AVE
Second Line	:
City	:	ROHNERT PARK
State	:	CA
Zip	:	94928-3613
Country	:	US
Telephone Number	:	707-664-4316
Fax Number	:	707-664-4104

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/08/2007

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