1760596860 NPI number — BACK TO LIFE LLC - BEN BOOHER DO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760596860 NPI number — BACK TO LIFE LLC - BEN BOOHER DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BACK TO LIFE LLC - BEN BOOHER DO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1760596860
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 53
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERMISTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97838-0053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-289-4555
Provider Business Mailing Address Fax Number:
541-289-4556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4309 W. 27TH PL.
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
KENNEWICK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-735-5433
Provider Business Practice Location Address Fax Number:
509-735-5435
Provider Enumeration Date:
08/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOOHER
Authorized Official First Name:
BEN
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
541-571-8201

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  OP1774 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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