=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114478872
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW PETER BOYESON DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2016
-----------------------------------------------------
Last Update Date | 01/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6030 SAINT ANDREWS RD STE M
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29212-3164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-238-3433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6030 SAINT ANDREWS RD STE M
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29212-3164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-238-3433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4349
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 5511
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------