Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 19388 | CA |
NPI | 1003943903 |
---|---|
Provider Name | Teryl Ryan Boothe |
First Address | Modesto, CA 95350-0832 |
Second Address | Modesto, CA 95350-0832 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/02/2007 |
Last Update Date | 08/07/2007 |