Healthcare Provider Details

I. General information

NPI: 1225499080
Provider Name (Legal Business Name): BOHANNAN MEDICAL DIST., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2016
Last Update Date: 03/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11417 N BOULDER CREEK CT
DUNLAP IL
61525-1500
US

IV. Provider business mailing address

11417 N BOULDER CREEK CT
DUNLAP IL
61525-1500
US

V. Phone/Fax

Practice location:
  • Phone: 309-678-8081
  • Fax:
Mailing address:
  • Phone: 309-678-8081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. TOMMY BOHANNAN
Title or Position: OWNER
Credential:
Phone: 309-678-8081