Provider Demographics
NPI:1699120907
Name:BOATWRIGHT, PEARL
Entity type:Individual
Prefix:
First Name:PEARL
Middle Name:
Last Name:BOATWRIGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 WELLESLEY ST
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-1576
Mailing Address - Country:US
Mailing Address - Phone:180-043-3806
Mailing Address - Fax:313-466-8035
Practice Address - Street 1:1605 WELLESLEY ST
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-1576
Practice Address - Country:US
Practice Address - Phone:180-043-3806
Practice Address - Fax:313-466-8035
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies