Healthcare Provider Details

I. General information

NPI: 1619295227
Provider Name (Legal Business Name): MR. BOSTON SNOWDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2010
Last Update Date: 05/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 NW 63RD ST
OKLAHOMA CITY OK
73116-7907
US

IV. Provider business mailing address

1309 SW 61ST TER
OKLAHOMA CITY OK
73159-2109
US

V. Phone/Fax

Practice location:
  • Phone: 405-848-2171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: