Healthcare Provider Details

I. General information

NPI: 1992087209
Provider Name (Legal Business Name): KEVIN KEITH BODLING D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 09/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TITUS RD SUITE 2
WASHINGTON DEPOT CT
06794-1516
US

IV. Provider business mailing address

PO BOX 337
WASHINGTON DEPOT CT
06794-0337
US

V. Phone/Fax

Practice location:
  • Phone: 888-852-2723
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License Number1798
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: