Healthcare Provider Details

I. General information

NPI: 1760184592
Provider Name (Legal Business Name): RONALD ONEAL BOSTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2023
Last Update Date: 03/17/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

184 KENTUCKY CIRCLE LITTLE ROCK AFB
JACKSONVILLE AR
72076
US

IV. Provider business mailing address

184 KENTUCKY CIRCLE LITTLE ROCK AFB
JACKSONVILLE AR
72076
US

V. Phone/Fax

Practice location:
  • Phone: 501-575-7490
  • Fax:
Mailing address:
  • Phone: 501-575-7490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number900118788
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: