MEDICARE: ELISABETH ROSS BOESHAAR

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	225700000X	Massage Therapist	MT.0017715	CO

General Provider Information

NPI Number	:	1528824505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELISABETH ROSS BOESHAAR

Provider Business Mailing Address
First Line	:	3154 LAKESIDE DR APT 103
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81506-2841
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3154 LAKESIDE DR APT 103
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81506-2841
Country	:	US
Telephone Number	:	760-486-8750
Fax Number	:

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

Provider Enumeration Date	:	02/26/2024
Last Update Date	:	02/26/2024

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