Healthcare Provider Details

I. General information

NPI: 1023297884
Provider Name (Legal Business Name): MR. BOONE S. KOWALIS SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15752 OAKHILL CT
LIVONIA MI
48154-2613
US

IV. Provider business mailing address

15752 OAKHILL CT
LIVONIA MI
48154-2613
US

V. Phone/Fax

Practice location:
  • Phone: 800-447-6038
  • Fax: 734-542-4289
Mailing address:
  • Phone: 800-447-6038
  • Fax: 734-542-4289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: