MEDICARE: DR. LAWRENCE BOUMA D.C.

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	111N00000X	Chiropractor	DC 001387 L	PA

General Provider Information

NPI Number	:	1255331393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAWRENCE BOUMA D.C.

Provider Business Mailing Address
First Line	:	102 CHRISTY PARK DR
Second Line	:
City	:	INDIANA
State	:	PA
Zip	:	15701-1584
Country	:	US
Telephone Number	:	724-465-4080
Fax Number	:	724-465-6923

Provider Business Practice Location Address
First Line	:	102 CHRISTY PARK DR
Second Line	:
City	:	INDIANA
State	:	PA
Zip	:	15701-1584
Country	:	US
Telephone Number	:	724-465-4080
Fax Number	:	724-465-6923

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

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	08/14/2012

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