MEDICARE: COREY PAUL BOYACK PTA

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	251E00000X	Home Health Agency
2	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1720274087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COREY PAUL BOYACK PTA

Provider Business Mailing Address
First Line	:	1051 EMERALD CT
Second Line	:
City	:	SARATOGA SPRINGS
State	:	UT
Zip	:	84045-8142
Country	:	US
Telephone Number	:	801-787-9166
Fax Number	:

Provider Business Practice Location Address
First Line	:	1051 EMERALD CT
Second Line	:
City	:	SARATOGA SPRINGS
State	:	UT
Zip	:	84045-8142
Country	:	US
Telephone Number	:	801-787-9166
Fax Number	:

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

Provider Enumeration Date	:	09/20/2007
Last Update Date	:	09/20/2007

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