MEDICARE: KENNETH J BOONE SR. MD - INTERN

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	101Y00000X	Counselor	CI5343	NV

General Provider Information

NPI Number	:	1679346290
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH J BOONE SR. MD - INTERN

Provider Business Mailing Address
First Line	:	4225 S EASTERN AVE., STE. 6
Second Line	:	UNIT 126
City	:	LAS VEGAS
State	:	NV
Zip	:	89119
Country	:	US
Telephone Number	:	716-308-0228
Fax Number	:

Provider Business Practice Location Address
First Line	:	1703 CIVIC CENTER DR STE 5
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-7273
Country	:	US
Telephone Number	:	716-308-0228
Fax Number	:

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

Provider Enumeration Date	:	11/06/2023
Last Update Date	:	11/06/2023

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