Healthcare Provider Details

I. General information

NPI: 1447469986
Provider Name (Legal Business Name): BOYZNBERRY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4003 CALLOWAY DR
MANSFIELD TX
76063-3448
US

IV. Provider business mailing address

4003 CALLOWAY DR
MANSFIELD TX
76063-3448
US

V. Phone/Fax

Practice location:
  • Phone: 817-727-3182
  • Fax: 682-518-5603
Mailing address:
  • Phone: 817-727-3182
  • Fax: 682-518-5603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number1027654
License Number StateTX

VIII. Authorized Official

Name: MR. STAN E BLACKBURN
Title or Position: PRESIDENT
Credential: MS,PT
Phone: 817-727-3182