Healthcare Provider Details

I. General information

NPI: 1619487501
Provider Name (Legal Business Name): BRYAN M BOOTH ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2017
Last Update Date: 10/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74910 AZTEC RD
PALM DESERT CA
92260-3101
US

IV. Provider business mailing address

80123 QUEENSBORO DR
INDIO CA
92201-0523
US

V. Phone/Fax

Practice location:
  • Phone: 916-880-8858
  • Fax:
Mailing address:
  • Phone: 916-880-8858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000026488
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: