Healthcare Provider Details

I. General information

NPI: 1043399884
Provider Name (Legal Business Name): TAVONA BOGGS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2770 LENOX RD NE
ATLANTA GA
30324-6006
US

IV. Provider business mailing address

5776 VILLAGE LOOP
FAIRBURN GA
30213-7932
US

V. Phone/Fax

Practice location:
  • Phone: 404-264-9553
  • Fax: 404-266-2294
Mailing address:
  • Phone: 770-551-5261
  • Fax: 770-551-5261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT008241
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: