Healthcare Provider Details

I. General information

NPI: 1134976376
Provider Name (Legal Business Name): BOSYONPLETOOTH A JOINER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 05/06/2024
Certification Date: 05/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9703 MOHAWK RIDGE DR
CONVERSE TX
78109-2767
US

IV. Provider business mailing address

9703 MOHAWK RIDGE DR
CONVERSE TX
78109-2767
US

V. Phone/Fax

Practice location:
  • Phone: 318-560-4544
  • Fax:
Mailing address:
  • Phone: 318-560-4544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number000000000
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: