Basic Information
| Provider Information | |||||||||
| NPI: | 1841757259 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BABOSA | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | ROZE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | YOUNG | ||||||||
| OtherFirstName: | JORDAN | ||||||||
| OtherMiddleName: | TYLER | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 21600 OXNARD ST STE 1800 | ||||||||
| Address2: | |||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913677807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183452345 | ||||||||
| FaxNumber: | 0000000000 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 W CUMMINGS PARK | ||||||||
| Address2: | |||||||||
| City: | WOBURN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018016369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3392274000 | ||||||||
| FaxNumber: | 7816346209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2019 | ||||||||
| LastUpdateDate: | 02/22/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.