=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902899875
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOSEPH BOEHM, P.T.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2005
-----------------------------------------------------
Last Update Date | 09/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2115 10TH ST SUITE B
-----------------------------------------------------
City | LOS OSOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93402-3244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-528-3002
-----------------------------------------------------
Fax | 805-528-5341
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2115 10TH ST SUITE B
-----------------------------------------------------
City | LOS OSOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93402-3244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-528-3002
-----------------------------------------------------
Fax | 805-528-5341
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JOSEPH BOEHM
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 805-528-3002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------