Healthcare Provider Details

I. General information

NPI: 1780915595
Provider Name (Legal Business Name): KENNETH BOGGS CO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2010
Last Update Date: 01/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 E SUPERIOR ST SUITE 1764
CHICAGO IL
60611-2654
US

IV. Provider business mailing address

2712 W FARWELL AVE
CHICAGO IL
60645-4515
US

V. Phone/Fax

Practice location:
  • Phone: 132-238-2810
  • Fax: 312-238-1932
Mailing address:
  • Phone: 773-972-1136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number213000065
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: