Basic Information
| Provider Information | |||||||||
| NPI: | 1043669088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOSS | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17332 VON KARMAN AVE | ||||||||
| Address2: | STE 120 | ||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926146282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9498618600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 17332 VON KARMAN AVE STE 120 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9498618600 | ||||||||
| FaxNumber: | 9498618601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2016 | ||||||||
| LastUpdateDate: | 08/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 294963 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT294963 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.