1356584932 NPI number — BOHO PAIN MANAGEMENT AND REHABILITATION LLC

Table of content: (NPI 1356584932)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356584932 NPI number — BOHO PAIN MANAGEMENT AND REHABILITATION LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOHO PAIN MANAGEMENT AND REHABILITATION LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356584932
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3715 LINDA LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RACINE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53405-4827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-554-9465
Provider Business Mailing Address Fax Number:
262-554-6354

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3701 DURAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RACINE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53405-4458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-497-8798
Provider Business Practice Location Address Fax Number:
262-554-6354
Provider Enumeration Date:
04/13/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BOHO
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
PRESIDENT AND OWNER
Authorized Official Telephone Number:
262-497-8798

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X , with the licence number:  919-026 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)