MEDICARE: KENNEDY CHRYSTIAN BOGGS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		FL

General Provider Information

NPI Number	:	1619487154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNEDY CHRYSTIAN BOGGS

Provider Business Mailing Address
First Line	:	126 TALL OAKS RD
Second Line	:
City	:	DEFUNIAK SPRINGS
State	:	FL
Zip	:	32435-8975
Country	:	US
Telephone Number	:	850-585-9189
Fax Number	:	850-951-0898

Provider Business Practice Location Address
First Line	:	171 STATE HIGHWAY 83 UNIT A-101
Second Line	:
City	:	DEFUNIAK SPRINGS
State	:	FL
Zip	:	32433-7427
Country	:	US
Telephone Number	:	850-585-9189
Fax Number	:	850-951-0898

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2017
Last Update Date	:	10/11/2017

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