Basic Information
| Provider Information | |||||||||
| NPI: | 1518011816 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOAZ & ASSOCIATES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DELTA REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1871 FALLS BLVD. NORTH | ||||||||
| Address2: | |||||||||
| City: | WYNNE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702088989 | ||||||||
| FaxNumber: | 8702088107 | ||||||||
| Practice Location | |||||||||
| Address1: | 1871 FALLS BLVD. NORTH | ||||||||
| Address2: | |||||||||
| City: | WYNNE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702088989 | ||||||||
| FaxNumber: | 8702088107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 08/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | BOULAND | ||||||||
| AuthorizedOfficialFirstName: | JO LYNN | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8702088989 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 145175742 | 05 | AR | MEDICAID |