Healthcare Provider Details

I. General information

NPI: 1275170706
Provider Name (Legal Business Name): RICHARD BOMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2019
Last Update Date: 12/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SUGAR ST
LAYTON UT
84041-4616
US

IV. Provider business mailing address

500 SUGAR ST
LAYTON UT
84041-4616
US

V. Phone/Fax

Practice location:
  • Phone: 435-512-9506
  • Fax:
Mailing address:
  • Phone: 435-512-9506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number289231-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: