Healthcare Provider Details

I. General information

NPI: 1023068749
Provider Name (Legal Business Name): LYNETTE BOSHOFF D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. LYNETTE DE LANGE

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 ELM GROVE RD SUITE 1
ELM GROVE WI
53122-2528
US

IV. Provider business mailing address

890 ELM GROVE RD SUITE 1
ELM GROVE WI
53122-2528
US

V. Phone/Fax

Practice location:
  • Phone: 414-617-0909
  • Fax:
Mailing address:
  • Phone: 414-617-0909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3869-012
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: