1962416149 NPI number — DR. KEITH L BOSTAPH DC

Table of content: DR. KEITH L BOSTAPH DC (NPI 1962416149)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962416149 NPI number — DR. KEITH L BOSTAPH DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOSTAPH
Provider First Name:
KEITH
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
M

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:
1962416149
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6053 SPINNAKER LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LADY LAKE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32159-5922
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-638-9090
Provider Business Mailing Address Fax Number:
352-638-9092

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6053 SPINNAKER LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LADY LAKE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32159-5922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-638-9090
Provider Business Practice Location Address Fax Number:
352-638-9092
Provider Enumeration Date:
07/27/2006

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: 111N00000X , with the licence number:  CH8400 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004450700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 70100 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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