1215667043 NPI number — MICHELLE MARIE BOYD R1470860622

Table of content: MICHELLE MARIE BOYD R1470860622 (NPI 1215667043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215667043 NPI number — MICHELLE MARIE BOYD R1470860622

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOYD
Provider First Name:
MICHELLE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
R1470860622
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215667043
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 586
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95709-0586
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-644-3758
Provider Business Mailing Address Fax Number:
530-644-2031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5494 PONY EXPRESS TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-644-3758
Provider Business Practice Location Address Fax Number:
530-644-2031
Provider Enumeration Date:
06/14/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  R1470860622 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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