Healthcare Provider Details

I. General information

NPI: 1205310828
Provider Name (Legal Business Name): CHARMAINE BOSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 E 84TH DR STE 205
MERRILLVILLE IN
46410-6399
US

IV. Provider business mailing address

233 E 84TH DR STE 205
MERRILLVILLE IN
46410-6399
US

V. Phone/Fax

Practice location:
  • Phone: 219-472-2062
  • Fax: 219-576-6090
Mailing address:
  • Phone: 219-472-2062
  • Fax: 219-576-6090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: