MEDICARE: ROBERT BOSTONIAN

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	324500000X	Substance Abuse Rehabilitation Facility	122932	CA

General Provider Information

NPI Number	:	1295104420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT BOSTONIAN

Provider Business Mailing Address
First Line	:	PO BOX 3517
Second Line	:
City	:	SAN RAFAEL
State	:	CA
Zip	:	94912-3517
Country	:	US
Telephone Number	:	415-535-5554
Fax Number	:

Provider Business Practice Location Address
First Line	:	67 GRANDE PASEO
Second Line	:
City	:	SAN RAFAEL
State	:	CA
Zip	:	94903-1555
Country	:	US
Telephone Number	:	415-535-5554
Fax Number	:

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

Provider Enumeration Date	:	09/17/2015
Last Update Date	:	09/17/2015

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