Healthcare Provider Details

I. General information

NPI: 1205245917
Provider Name (Legal Business Name): DEVON BOONE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 09/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3427 4TH AVE FL 2
SAN DIEGO CA
92103-4910
US

IV. Provider business mailing address

3427 4TH AVE FL 2
SAN DIEGO CA
92103-4910
US

V. Phone/Fax

Practice location:
  • Phone: 619-525-9903
  • Fax: 619-525-9908
Mailing address:
  • Phone: 619-525-9903
  • Fax: 619-525-9908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number72191
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: