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General NPI Number Information
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NPI Number | 1003112558
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Entity Type | Organization
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Legal Business Name | J BOATMAN LLC
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Dates
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Enumeration Date | 02/01/2011
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Last Update Date | 10/10/2022
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Provider Practice Location Address
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Address Line | 11475 OLDE CABIN RD STE 120
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City | CREVE COEUR
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State | MO
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Zip | 63141-7128
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Country | US
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Telephone | 314-647-4488
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Fax | 314-647-6305
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Provider Business Mailing Address
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Address Line | 5807 MANGO DR
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City | SAINT LOUIS
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State | MO
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Zip | 63129-2243
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Country | US
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Telephone | 314-753-5184
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JEFFREY BOATMAN
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Credential | MSN
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Telephone | 314-753-5184
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WP0809X
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Taxonomy Name | Adult Psychiatric/Mental Health Registered Nurse
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License Number | 11805
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License Number State | MO
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