MEDICARE: BOUMA CHIROPRACTIC CLINIC, P.C.

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	111N00000X	Chiropractor	DC001387L	PA

General Provider Information

NPI Number	:	1043258049
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOUMA CHIROPRACTIC CLINIC, P.C.

Provider Business Mailing Address
First Line	:	102 CHRISTY PARK DR
Second Line	:
City	:	INDIANA
State	:	PA
Zip	:	15701-1584
Country	:	US
Telephone Number	:	724-465-4080
Fax Number	:	724-465-6923

Provider Business Practice Location Address
First Line	:	102 CHRISTY PARK DR
Second Line	:
City	:	INDIANA
State	:	PA
Zip	:	15701-1584
Country	:	US
Telephone Number	:	724-465-4080
Fax Number	:	724-465-6923

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LAWRENCE BOUMA
Credential	:	D.C.
Telephone Number	:	724-465-4080

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	08/22/2020

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