MEDICARE: BOBBYBOOTCAMPS

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	172V00000X	Community Health Worker	MT037974	TX

General Provider Information

NPI Number	:	1659776045
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOBBYBOOTCAMPS

Provider Business Mailing Address
First Line	:	2960 DONNELL DR
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78664-5709
Country	:	US
Telephone Number	:	512-771-8609
Fax Number	:

Provider Business Practice Location Address
First Line	:	2960 DONNELL DR
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78664-5709
Country	:	US
Telephone Number	:	512-771-8609
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BOBBY C CRAIG
Credential	:	LMT
Telephone Number	:	512-771-8609

Provider Enumeration Date	:	10/28/2014
Last Update Date	:	10/28/2014

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Directions to “BOBBYBOOTCAMPS ” Practice Location

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