Provider Demographics
NPI:1457430183
Name:BOSWELLIA CORP
Entity type:Organization
Organization Name:BOSWELLIA CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO,ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RORI
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:CORYATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-675-1572
Mailing Address - Street 1:228 N PRAIRIEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-2043
Mailing Address - Country:US
Mailing Address - Phone:903-675-1572
Mailing Address - Fax:903-675-1963
Practice Address - Street 1:228 N PRAIRIEVILLE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-2043
Practice Address - Country:US
Practice Address - Phone:903-675-1572
Practice Address - Fax:903-675-1963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX009401251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN673137Medicare ID - Type UnspecifiedPROVIDER NUMBER