Healthcare Provider Details

I. General information

NPI: 1508348772
Provider Name (Legal Business Name): KAREN BOESCH- LEVERETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 09/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 SHERATON BLVD
MACON GA
31210-1359
US

IV. Provider business mailing address

115 RIVER OVERLOOK
FORSYTH GA
31029-4859
US

V. Phone/Fax

Practice location:
  • Phone: 678-427-7570
  • Fax:
Mailing address:
  • Phone: 678-427-7570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number001105
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: