Basic Information
| Provider Information | |||||||||
| NPI: | 1316213457 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOYER | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1565 | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917291565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006425031 | ||||||||
| FaxNumber: | 9099897633 | ||||||||
| Practice Location | |||||||||
| Address1: | 8655 HAVEN AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917304891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006425031 | ||||||||
| FaxNumber: | 9099897633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2012 | ||||||||
| LastUpdateDate: | 03/22/2012 | ||||||||
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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 | 225200000X | AT-4792 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.