Healthcare Provider Details

I. General information

NPI: 1841375920
Provider Name (Legal Business Name): TIMOTHY PAUL KEILY BOCO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

-2 WRAMC SUITE 3H 6900 GEORGIA AVE. NW
WASHINGTON DC
20307-0001
US

IV. Provider business mailing address

7807 LELAND RD
MANASSAS VA
20111-1944
US

V. Phone/Fax

Practice location:
  • Phone: 202-782-6385
  • Fax: 202-782-9080
Mailing address:
  • Phone: 703-369-2044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberC22227
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: