Healthcare Provider Details

I. General information

NPI: 1144328550
Provider Name (Legal Business Name): BO ERNEST OWENS ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 E COTATI AVE
ROHNERT PARK CA
94928-3613
US

IV. Provider business mailing address

5349 EUNICE ST
ROHNERT PARK CA
94928-1822
US

V. Phone/Fax

Practice location:
  • Phone: 707-664-4316
  • Fax: 707-664-4104
Mailing address:
  • Phone: 707-586-2860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: