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General NPI Number Information
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NPI Number | 1922370857
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Entity Type | Individual
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Provider Name | BRIAN CLARK BOESE DPT
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Gender | Male
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Dates
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Enumeration Date | 02/08/2012
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 10415 GRAND RIVER RD STE 300
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City | BRIGHTON
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State | MI
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Zip | 48116-6533
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Country | US
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Telephone | 810-229-6140
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Fax | 810-229-6145
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Provider Business Mailing Address
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Address Line | 790 REMINGTON BLVD
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City | BOLINGBROOK
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State | IL
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Zip | 60440-4909
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Country | US
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Telephone | 810-229-6140
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 004883
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License Number State | IA
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 60259
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 5501018260
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License Number State | MI
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