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General NPI Number Information
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NPI Number | 1114972627
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Entity Type | Organization
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Legal Business Name | HAVEN PHYSICAL THERAPY
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Dates
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Enumeration Date | 05/23/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 7974 HAVEN AVE SUITE 215
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-3061
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Country | US
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Telephone | 909-481-5304
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Fax | 909-481-5307
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Provider Business Mailing Address
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Address Line | 7974 HAVEN AVE SUITE 290
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-3061
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Country | US
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Telephone | 909-481-5304
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Fax | 909-481-5307
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRIAN DOUGLAS BOEKHOUT
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Credential | PT
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Telephone | 909-481-5304
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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