Healthcare Provider Details

I. General information

NPI: 1497239545
Provider Name (Legal Business Name): BOOMERANG TRADING COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 DEMPSTER ST APT EG1
MOUNT PROSPECT IL
60056-5020
US

IV. Provider business mailing address

700 DEMPSTER ST APT EG1
MOUNT PROSPECT IL
60056-5020
US

V. Phone/Fax

Practice location:
  • Phone: 929-326-3063
  • Fax:
Mailing address:
  • Phone: 929-326-3063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name: AZAT OVEZOV
Title or Position: OWNER
Credential:
Phone: 929-326-3063