Provider Demographics
NPI:1598217887
Name:BOSTICK, ROY LUCAS
Entity type:Individual
Prefix:MR
First Name:ROY
Middle Name:LUCAS
Last Name:BOSTICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 MINERS RAVINE RD
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-9335
Mailing Address - Country:US
Mailing Address - Phone:916-878-0741
Mailing Address - Fax:
Practice Address - Street 1:1425 FULTON RD
Practice Address - Street 2:SUITE 315
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-7618
Practice Address - Country:US
Practice Address - Phone:707-545-7014
Practice Address - Fax:707-526-6739
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA7278237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA7278OtherCALIFORNIA HEARING AID DISPENSER LICENSE HA7278