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General NPI Number Information
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NPI Number | 1447469986
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Entity Type | Organization
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Legal Business Name | BOYZNBERRY CORPORATION
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Dates
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Enumeration Date | 05/22/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4003 CALLOWAY DR
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City | MANSFIELD
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State | TX
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Zip | 76063-3448
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Country | US
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Telephone | 817-727-3182
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Fax | 682-518-5603
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Provider Business Mailing Address
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Address Line | 4003 CALLOWAY DR
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City | MANSFIELD
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State | TX
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Zip | 76063-3448
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Country | US
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Telephone | 817-727-3182
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Fax | 682-518-5603
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. STAN E BLACKBURN
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Credential | MS,PT
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Telephone | 817-727-3182
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number | 1027654
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License Number State | TX
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