Healthcare Provider Details

I. General information

NPI: 1619176948
Provider Name (Legal Business Name): KEVIN R BOBOS OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11708 PURE PEBBLE DR
RIVERVIEW FL
33569-9008
US

IV. Provider business mailing address

11708 PURE PEBBLE DR
RIVERVIEW FL
33569-9008
US

V. Phone/Fax

Practice location:
  • Phone: 813-741-1332
  • Fax:
Mailing address:
  • Phone: 813-741-1332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number12771
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: