Healthcare Provider Details

I. General information

NPI: 1831606227
Provider Name (Legal Business Name): CYNTHIA L BOGACKI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2018
Last Update Date: 01/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 S ROCK CREEK PKWY APT 14-101
SUPERIOR CO
80027-4414
US

IV. Provider business mailing address

2300 S ROCK CREEK PKWY APT 14-101
SUPERIOR CO
80027-4414
US

V. Phone/Fax

Practice location:
  • Phone: 618-520-7504
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number041433621
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number1647997
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: