Healthcare Provider Details

I. General information

NPI: 1083281000
Provider Name (Legal Business Name): MR. STACEY R BOYLES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 KIRKWOOD HWY STE 101
ELSMERE DE
19805-4939
US

IV. Provider business mailing address

1702 KIRKWOOD HWY STE 101
ELSMERE DE
19805-4939
US

V. Phone/Fax

Practice location:
  • Phone: 302-507-1075
  • Fax:
Mailing address:
  • Phone: 302-777-0778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-0004819
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: