Healthcare Provider Details

I. General information

NPI: 1629185103
Provider Name (Legal Business Name): KEVIN BOATRIGHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 11/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N WASHINGTON ST SUITE 5
FARMINGTON MO
63640-1751
US

IV. Provider business mailing address

670 MASON RIDGE CENTER DR SUITE 300
SAINT LOUIS MO
63141-8573
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-1744
  • Fax: 573-756-2499
Mailing address:
  • Phone: 573-756-1744
  • Fax: 573-756-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberR7D62
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR7D62
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: