Provider Demographics
NPI:1619487501
Name:BOOTH, BRYAN M (ATC)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:M
Last Name:BOOTH
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80123 QUEENSBORO DR
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-0523
Mailing Address - Country:US
Mailing Address - Phone:916-880-8858
Mailing Address - Fax:
Practice Address - Street 1:74910 AZTEC RD
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-3101
Practice Address - Country:US
Practice Address - Phone:916-880-8858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000264882255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer