MEDICARE: DR. ODETTE BOYD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	94024879	CA

General Provider Information

NPI Number	:	1003420142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ODETTE BOYD PA

Provider Business Mailing Address
First Line	:	10808 FOOTHILL BLVD # 626
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91730-3889
Country	:	US
Telephone Number	:	424-230-9276
Fax Number	:

Provider Business Practice Location Address
First Line	:	5101 E LA PALMA AVE STE 100
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92807-2056
Country	:	US
Telephone Number	:	442-229-5636
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2020
Last Update Date	:	09/05/2020

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