MEDICARE: MARIA LARNIE BOQUIREN ATC

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	2255A2300X	Athletic Trainer		AZ

General Provider Information

NPI Number	:	1356386114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA LARNIE BOQUIREN ATC

Provider Business Mailing Address
First Line	:	9037 HUBBARD ST
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90232-2508
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9037 HUBBARD ST
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90232-2508
Country	:	US
Telephone Number	:	480-648-7374
Fax Number	:

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

Provider Enumeration Date	:	06/17/2006
Last Update Date	:	07/08/2007

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