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General NPI Number Information
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NPI Number | 1669928834
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Entity Type | Organization
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Legal Business Name | BOULDERWOOD ESTATES LLC
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Dates
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Enumeration Date | 08/28/2016
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Last Update Date | 08/28/2016
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Provider Practice Location Address
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Address Line | 1111 CARE AVE
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City | NIXA
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State | MO
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Zip | 65714-9679
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Country | US
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Telephone | 417-374-7755
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 870
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City | NIXA
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State | MO
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Zip | 65714-0870
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | KEVIN EDMONDS
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Credential |
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Telephone | 417-860-1300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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